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| {{CMG}}{{AE}}{{VD}}
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| {{SK}}
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| ==Overview==
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| Balanitis xerotica obliterans (BXO) is a dermatological (skin) condition affecting the male genitalia. It was first described by Stuhmer in 1928, though earlier reports describe what may have been the same condition.[1] BXO commonly occurs on the foreskin and glans penis.[2] Atrophic white patches appear on the affected area,[3] and commonly, a whitish ring of indurated (hardened) tissue usually forms near the tip that may prevent retraction.[2]
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| ==Historical Perspective==
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| *In 1952, for the first time in medical literature, Zoon recognized a distinct entity in patients with chronic balanitis, named it as balanoposthite chronique circonscrite bénigne á plasmocytes” or “balanitis chronica circumscripta plasmacellularis.<ref name="pmid129795762">{{cite journal| author=ZOON JJ| title=[Chronic benign circumscript plasmocytic balanoposthitis]. | journal=Dermatologica | year= 1952 | volume= 105 | issue= 1 | pages= 1-7 | pmid=12979576 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12979576 }}</ref>
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| *In 1954, Garnier reported the similar lesion in vulva.<ref name="pmid70739842">{{cite journal| author=Sonnex TS, Dawber RP, Ryan TJ, Ralfs IG| title=Zoon's (plasma-cell) balanitis: treatment by circumcision. | journal=Br J Dermatol | year= 1982 | volume= 106 | issue= 5 | pages= 585-8 | pmid=7073984 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7073984 }}</ref>
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| *In 1956, Nikolowski described the identical lesion in oral mucosa.<ref name="pmid133407892">{{cite journal| author=NIKOLOWSKI W, WIEHL R| title=[Not Available]. | journal=Arch Klin Exp Dermatol | year= 1956 | volume= 202 | issue= 4 | pages= 347-57 | pmid=13340789 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13340789 }}</ref>
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| *In 1963, Kortnig described the idential lesion in conjuntiva.<ref name="pmid140981192">{{cite journal| author=KORTING GW, THEISEN H| title=[CIRCUMSCRIBED PLASMA CELL BALANOPOSTHITIS AND CONJUNCTIVITIS IN THE SAME PATIENT]. | journal=Arch Klin Exp Dermatol | year= 1963 | volume= 217 | issue= | pages= 495-504 | pmid=14098119 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14098119 }}</ref>
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| ==Classification==
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| There is no established classification system for Zoon balanitis.
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| ==Pathophysiology==
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| ===Pathogenesis===
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| The exact pathogenesis is not clearly known, but following theories have been postulated:<ref name="pmid113199702">{{cite journal| author=Porter WM, Bunker CB| title=The dysfunctional foreskin. | journal=Int J STD AIDS | year= 2001 | volume= 12 | issue= 4 | pages= 216-20 | pmid=11319970 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11319970 }}</ref>
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| *Accumlation of epithelial debris and secretions between foreskin and penis proximal to coronal sulcus, smegma, poor genital hygiene, repeated local infections, hot and humid weather results in chronic physical irritation or subclinical trauma, which in turn results in skin lesion along the lines of the trauma.
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| *Chronic infection with ''Mycobacterium smegmatis'' and human papillomaviruses (HPV) was found to be associated with development of Zoon balanitis.<ref name="pmid155885602">{{cite journal| author=Pastar Z, Rados J, Lipozencić J, Skerlev M, Loncarić D| title=Zoon plasma cell balanitis: an overview and role of histopathology. | journal=Acta Dermatovenerol Croat | year= 2004 | volume= 12 | issue= 4 | pages= 268-73 | pmid=15588560 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15588560 }}</ref>
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| *Many theories, which include 1) local disturbance of circulation, 2) hypersensitivity response mediated by IgE class of antibodies, 3) “extramedullary plasmacytic infiltrations that persists are expressions of occult multiple myeloma” have been postulated, no supportive evidence have been found for these hypothesis.<ref name="pmid124545963">{{cite journal| author=Weyers W, Ende Y, Schalla W, Diaz-Cascajo C| title=Balanitis of Zoon: a clinicopathologic study of 45 cases. | journal=Am J Dermatopathol | year= 2002 | volume= 24 | issue= 6 | pages= 459-67 | pmid=12454596 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12454596 }}</ref>
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| ====Histopathology====
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| ZB has distinctive histopathological features, which include:<ref name="pmid1245459622">{{cite journal| author=Weyers W, Ende Y, Schalla W, Diaz-Cascajo C| title=Balanitis of Zoon: a clinicopathologic study of 45 cases. | journal=Am J Dermatopathol | year= 2002 | volume= 24 | issue= 6 | pages= 459-67 | pmid=12454596 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12454596 }}</ref>
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| ====Epidermal====
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| *Epidermal changes include, early thickening, acanthosis and parakeratosis of epidermis, which is followed by atrophy, erosions and spongiosis.
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| *Scattered neutrophils can be present in superficial erosions of the epidermis.
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| *Spongiosis accentuation occurs in the lower half of the spinous zone.
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| *Subepidermal clefts, necrotic keratinocytes, and lozenge keratinocytes can be seen in the late stages of ZB.
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| ====Dermal====
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| *Dermal changes include patchy lichenoid infiltrate of lymphocytes and plasma cells in papillary dermis, which are replaced by plasma cells, neutrophils, eosinophils, lymphocytes, and erythrocytes.
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| *Dermal vascular dilatation with singular vertical or oblique orientation of proliferated individual vessels, is a characteristic feature of ZB.
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| *In the later stages, upper dermis shows fibrosis which correlates well with subepidermal clefts, epidermal atrophy, and plasma cell infiltrates.
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| ==Causes==
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| The etiology of BXO is uncertain. However, some possibilities have been suggested.
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| Some studies have shown that patients with BXO also show signs of suffering from [[autoimmunity|autoimmune]] disorders.<ref name="azurdia1999">{{cite journal | author = Azurdia R, Luzzi G, Byren I, Welsh K, Wojnarowska F, Marren P, Edwards A | title = Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease. | journal = Br J Dermatol | volume = 140 | issue = 1 | pages = 79-83 | year = 1999 | month = Jan | id = PMID 10215772}}</ref><!--
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| --><ref name="meyrickthomas1983">{{cite journal | author = Meyrick Thomas R, Ridley C, Black M | title = The association of lichen sclerosus et atrophicus and autoimmune-related disease in males. | journal = Br J Dermatol | volume = 109 | issue = 6 | pages = 661-4 | year = 1983 | month = Dec | id = PMID 6652042}}</ref><!--
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| --><ref name="harrington1981">{{cite journal | author = Harrington C, Dunsmore I | title = An investigation into the incidence of auto-immune disorders in patients with lichen sclerosus and atrophicus. | journal = Br J Dermatol | volume = 104 | issue = 5 | pages = 563-6 | year = 1981 | month = May | id = PMID 7236515}}</ref>
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| However, this finding is not repeated in every study.<ref name="meyrickthomas1983" />
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| Infection from "[[human papilloma virus]] (serotype 16 in particular), [[spirochaete|spirochetes]] and atypical [[mycobacterium|mycobacteria]]" has also been suggested as a cause.<ref name="kizer2003" /> Additional suggestions include "[[pemphigus|pemphigus vulgaris]] and chronic nonspecific bacterial [[balanitis]]".<!--
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| --><ref name="edwards1996">{{cite journal | author=Edwards S. | title=Balanitis and balanoposthitis: a review | journal=Genitourin Med | year= 1996 | month= | volume=72 | issue=3 | pages=155-9 | id= | url=http://www.circs.org/library/edwards/ | format=Reprint:The CIRP Circumcision Reference Library}}</ref>
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|
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| ===Relationship to phimosis===
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| BXO is a common cause of pathological [[phimosis]].<ref name="keogh2005" /><ref name="buechner2002" />
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| Kiss ''et al.'' report that 40% of boys with phimosis suffered from BXO.<!--
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| --><ref name="kiss2005">{{cite journal | author = Kiss A, Király L, Kutasy B, Merksz M | title = High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study. | journal = Pediatr Dermatol | volume = 22 | issue = 4 | pages = 305-8 | year = 2005 | month = Jul-Aug | id = PMID 16060864}}</ref>
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| Shankar and Rickwood reported BXO in 84% of phimosis patients.<ref name="shankar1999" /> Evans reported BXO in 10.5% of phimosis patients.<!--
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| --><ref name="evans2000">{{cite journal | author = Evans D | title = Retrospective study of male lichen sclerosus and outcome in Leicester: 1995-9 inclusive: experience of a genitourinary medicine clinic. | journal = Sex Transm Infect | volume = 76 | issue = 6 | pages = 495 | year = 2000 | id = PMID 11221136 | url=http://sti.bmjjournals.com/cgi/content/full/76/6/495}}</ref>
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| Clemmensen ''et al.'' reported BXO in 14.2% of phimosis patients.<!--
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| --><ref name="clemmensen1988">{{cite journal | author = Clemmensen O, Krogh J, Petri M | title = The histologic spectrum of prepuces from patients with phimosis. | journal = Am J Dermatopathol | volume = 10 | issue = 2 | pages = 104-8 | year = 1988 | month = Apr | id = PMID 3239715}}</ref>
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| Bale reported that BXO was found in 19% of circumcisions performed for diseases of the prepuce and penis.<!--
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| --><ref name="bale1987">{{cite journal | author = Bale P, Lochhead A, Martin H, Gollow I | title = Balanitis xerotica obliterans in children. | journal = Pediatr Pathol | volume = 7 | issue = 5-6 | pages = 617-27 | year = 1987 | id = PMID 3449818}}</ref>
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| Mattioli observed BXO in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis.<!--
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| --><ref name="mattioli2002">{{cite journal | author = Mattioli G, Repetto P, Carlini C, Granata C, Gambini C, Jasonni V | title = Lichen sclerosus et atrophicus in children with phimosis and hypospadias. | journal = Pediatr Surg Int | volume = 18 | issue = 4 | pages = 273-5 | year = 2002 | month = May | id = PMID 12021978}}</ref>
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| Rickwood reported BXO in 20 of 21 patients circumcised for pathological phimosis.<!--
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| --><ref name="rickwood1980">{{cite journal | author=Rickwood AMK, Hemalatha V, Batcup G, Spitz L. | title=Phimosis in boys | journal=Brit J Urol | year=1980 | month= | volume=52 | issue= | pages=147-50 | id= | url=http://www.cirp.org/library/treatment/phimosis/rickwood/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate= }}</ref>
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|
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| ===Relationship to lichen sclerosus===
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| Many researchers regard BXO as [[lichen sclerosus et atrophicus]] (LSA) of the penis, LSA is also known as [[lichen sclerosus]] (LS). Lately BXO was coded as part of LSA by Medical literature search tool [[MEDLINE|Medline]].<!--
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| --><ref name="finkbeiner2003">{{cite journal | author = Finkbeiner A | title = Balanitis xerotica obliterans: a form of lichen sclerosus. | journal = South Med J | volume = 96 | issue = 1 | pages = 7-8 | year = 2003 | month = Jan | id = PMID 12602704 | url=http://www.smajournalonline.com/pt/re/smj/fulltext.00007611-200301000-00003.htm}}</ref><!--
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| --><ref name="laymon1944">{{cite journal | author=Laymon CW, Freeman C. | title=Relationship of balanitis xerotica obliterans to lichen sclerosus et atrophicus | journal=Arch Dermat Syph | year=1944 | month= | volume=49 | issue= | pages=57-9 | id= | url=http://www.cirp.org/library/treatment/BXO/laymon1/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate= }}</ref><!--
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| --><ref name="neill2002">{{cite journal | author = Neill S, Tatnall F, Cox N | title = Guidelines for the management of lichen sclerosus. | journal = Br J Dermatol | volume = 147 | issue = 4 | pages = 640-9 | year = 2002 | month = Oct | id = PMID 12366407}}</ref>
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| However, Mallon ''et al.'' suggest that BXO "may be a consequence of other fibrosing [[dermatosis|dermatoses]], such as [[lichen planus]] and cicatricial pemphigoid."<ref name="mallon2000" /> When occurring on the male genitals, the term 'BXO' is traditionally used.<ref name="keogh2005" />
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|
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| ==Epidemiology and Demographics==
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| The true [[prevalence]] of BXO is controversial and unclear. One study calculated a rate of 0.6% of boys affected by their 15th birthday.<!--
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| --><ref name="shankar1999">{{cite journal | author = Shankar K, Rickwood A | title = The incidence of phimosis in boys. | journal = BJU Int | volume = 84 | issue = 1 | pages = 101-2 | year = 1999 | month = Jul | id = PMID 10444134}}</ref>
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| Another reported a rate of 0.07%.<!--
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| --><ref name="kizer2003">{{cite journal | author = Kizer W, Prarie T, Morey A | title = Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system. | journal = South Med J | volume = 96 | issue = 1 | pages = 9-11 | year = 2003 | month = Jan | id = PMID 12602705}}</ref>
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| However, a review noted that "with a high degree of suspicion and [[histology|histologic]] examination, the condition will prove to be much more frequent than one generally believes."<!--
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| --><ref name="das2000">{{cite journal | author = Das S, Tunuguntla H | title = Balanitis xerotica obliterans--a review. | journal = World J Urol | volume = 18 | issue = 6 | pages = 382-7 | year = 2000 | month = Dec | id = PMID 11204255}}</ref>
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| Another suggested that "more cases would be [[diagnosis|diagnosed]] during infancy if all dried foreskin were examined systematically."<!--
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| --><ref name="garat1986">{{cite journal | author = Garat J, Chéchile G, Algaba F, Santaularia J | title = Balanitis xerotica obliterans in children. | journal = J Urol | volume = 136 | issue = 2 | pages = 436-7 | year = 1986 | month = Aug | id = PMID 3735511}}</ref>
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| Another remarked that the condition "may be misdiagnosed or ignored in the young boy."<!--
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| --><ref name="mckay1975">{{cite journal | author = McKay D, Fuqua F, Weinberg A | title = Balanitis xerotica obliterans in children. | journal = J Urol | volume = 114 | issue = 5 | pages = 773-5 | year = 1975 | month = Nov | id = PMID 1237636}}</ref>
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| Yet another commented that "its true incidence is not appreciated because most cases are cured by [[circumcision]], and unfortunately many surgeons still fail to send their circumcision specimens for histology."<!--
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| --><ref name="depasquale2000">{{cite journal | author=Depasquale I, Park AJ, Bracka A. | title=The treatment of balanitis xerotica obliterans | journal=BJU Int | year=2000 | month= | volume=86 | issue=4 | pages=459-65 | id= | url=http://www.cirp.org/library/treatment/BXO/depasquale1/ | format=Reprint:The CIRP Circumcision Reference Library | accessdate=2006-10-01 }}</ref>
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| Another remarked that the "extent of [[asymptomatic]] disease in this series would suggest the true prevalence of LS in men might be much higher than published work suggests."<!--
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| --><ref name="riddell2000">{{cite journal | author=Riddell I, Edwards A, Sherrard J. | title=Clinical features of lichen sclerosus in men attending a department of genitourinary medicine | journal=Sex Trans Infect | year=2000 | month=Aug | volume=76 | issue=4 | pages=311-3 | id= | url=http://sextrans.bmjjournals.com/cgi/content/full/76/4/311}}</ref>
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| According to some authors, the disease most frequently affects middle-aged men.<ref name="keogh2005" /> However, a large study reported that the age distribution was similar from 2 to 90 years of age, except for men in their twenties, who were at twice the risk.<ref name="kizer2003" /> The same study found that [[black people|black]] and [[Hispanic]] men had approximately twice the risk of white men. The authors suggested possible reasons for this, including access to health care, differences in neonatal circumcision rates, and climate differences.
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| Mallon ''et al.'' found that BXO was related to circumcision status. Adjusting for age, lack of circumcision was associated with an [[odds ratio]] of 53.55. The finding was [[statistical significance|statistically significant]].<ref name="mallon2000">{{cite journal | author = Mallon E, Hawkins D, Dinneen M, Francics N, Fearfield L, Newson R, Bunker C | title = Circumcision and genital dermatoses. | journal = Arch Dermatol | volume = 136 | issue = 3 | pages = 350-4 | year = 2000 | month = Mar | id = PMID 10724196}}</ref>
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| However, BXO has also been noted to occur after late circumcision, especially when performed for [[phimosis]].<ref name="freeman1941" /><ref name="mallon2000" /><ref name="kizer2003" />
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|
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| ==Screening==
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| There is no established screening guidelines for Zoon balanitis
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| ==Natural History, Complications, and Prognosis==
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| ===Natural history===
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| If left untreated, there is risk for malignant transformation.<ref name="pmid27890945">{{cite journal| author=Dayal S, Sahu P| title=Zoon balanitis: A comprehensive review. | journal=Indian J Sex Transm Dis | year= 2016 | volume= 37 | issue= 2 | pages= 129-138 | pmid=27890945 | doi=10.4103/0253-7184.192128 | pmc=5111296 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27890945 }}</ref>
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|
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| ===Complications===
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| Complications of Zoon balanitis include:
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| * Phimosis
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| * Paraphimosis
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|
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| ===Prognosis===
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|
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| BXO is chronic and often progressive.<ref name="keogh2005" /> Please see the following section on treatment.
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|
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| The condition may cause [[Pain and nociception|pain]], [[irritation]], and disturbance of [[sex|sexual function]].<ref name="edwards1996" />
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| In later stages, a [[meatus|meatal]] [[stenosis|stricture]] may occur, causing [[urinary retention]].<ref name="freeman1941" /><ref name="keogh2005" /> This may result in [[Urinary bladder|bladder]] or [[kidney]] damage.<ref name="keogh2005" />
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| The coronal sulcus and [[frenulum]] may be destroyed.<ref name="keogh2005" />
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|
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| [[Phimosis]] or [[paraphimosis]] may occur.<ref name="keogh2005" />
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| Several studies indicate that BXO may play a pre-[[cancer|cancerous]] role,<!--
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| --><ref name="velazquez2003">{{cite journal | author = Velazquez E, Cubilla A | title = Lichen sclerosus in 68 patients with squamous cell carcinoma of the penis: frequent atypias and correlation with special carcinoma variants suggests a precancerous role. | journal = Am J Surg Pathol | volume = 27 | issue = 11 | pages = 1448-53 | year = 2003 | month = Nov | id = PMID 14576478}}</ref><!--
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| --><ref name="cubilla2004">{{cite journal | author = Cubilla A, Velazquez E, Young R | title = Pseudohyperplastic squamous cell carcinoma of the penis associated with lichen sclerosus. An extremely well-differentiated, nonverruciform neoplasm that preferentially affects the foreskin and is frequently misdiagnosed: a report of 10 cases of a distinctive clinicopathologic entity. | journal = Am J Surg Pathol | volume = 28 | issue = 7 | pages = 895-900 | year = 2004 | month = Jul | id = PMID 15223959}}</ref><!--
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| --><ref name="perceau2003">{{cite journal | author = Perceau G, Derancourt C, Clavel C, Durlach A, Pluot M, Lardennois B, Bernard P | title = Lichen sclerosus is frequently present in penile squamous cell carcinomas but is not always associated with oncogenic human papillomavirus. | journal = Br J Dermatol | volume = 148 | issue = 5 | pages = 934-8 | year = 2003 | month = May | id = PMID 12786823}}</ref><!--
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| --><ref name="powell2001">{{cite journal | author = Powell J, Robson A, Cranston D, Wojnarowska F, Turner R | title = High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis. | journal = Br J Dermatol | volume = 145 | issue = 1 | pages = 85-9 | year = 2001 | month = Jul | id = PMID 11453912}}</ref><!--
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| --><ref name="micali2001">{{cite journal | author = Micali G, Nasca M, Innocenzi D | title = Lichen sclerosus of the glans is significantly associated with penile carcinoma. | journal = Sex Transm Infect | volume = 77 | issue = 3 | pages = 226 | year = 2001 | month = Jun | id = PMID 11402247 | url=http://sti.bmjjournals.com/cgi/content/full/77/3/226}}</ref>
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| resulting in [[squamous cell carcinoma]] of the penis, a form of [[penile cancer]].
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|
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|
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| Prognosis is good with treatment.<ref name="pmid278909452">{{cite journal| author=Dayal S, Sahu P| title=Zoon balanitis: A comprehensive review. | journal=Indian J Sex Transm Dis | year= 2016 | volume= 37 | issue= 2 | pages= 129-138 | pmid=27890945 | doi=10.4103/0253-7184.192128 | pmc=5111296 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27890945 }}</ref>
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|
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| ==Diagnosis==
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| Neuhaus and Skidmore report that "[[Tzanck smear]] and [[skin|cutaneous]] [[biopsy]], along with a rapid protein reagin test, will provide a definitive diagnosis."<!--
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| --><ref name="neuhaus1999">{{cite journal | author = Neuhaus I, Skidmore R | title = Balanitis xerotica obliterans and its differential diagnosis. | journal = J Am Board Fam Pract | volume = 12 | issue = 6 | pages = 473-6 | year = 1999 | month = Nov-Dec | id = PMID 10612365}}</ref>
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|
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| Depasquale ''et al.'' note that many surgeons do not send circumcision specimens for histology. They caution that this practice "is becoming medicolegally indefensible in a litigation-conscious society, where the clinical sequelae of BXO are often misinterpreted by the patient as surgical errors."<ref name="depasquale2000" />
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|
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| ===History and symptoms===
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| Patients with Zoon balanitits could be asymptomatic or present with:<ref name="pmid248285532">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553 }}</ref>
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| *Itching (pruritus) of the genitalia.
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| *Discomfort in urination(dysuria)
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| *Pain in the gential region
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| *blood stain discharge
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| *Difficult or painful sexual intercourse
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| ===Physical examination===
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| Physical examination findings include:<ref name="pmid155885602" /><ref name="pmid172415662">{{cite journal| author=Kumar B, Narang T, Dass Radotra B, Gupta S| title=Plasma cell balanitis: clinicopathologic study of 112 cases and treatment modalities. | journal=J Cutan Med Surg | year= 2006 | volume= 10 | issue= 1 | pages= 11-5 | pmid=17241566 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17241566 }}</ref>
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| * Well circumscribed single or multiple, orange-red in colour with a characteristic glazed appearance and multiple pinpoint redder spots-"cayenne pepper spots"(please [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111296/figure/F2/ click here] to view the image) most commonly involving the glans penis, but inner surface of prepuce and coronal sulcus may be involved.
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| * Though uncommon, lesions of Zoon balanitis can involve other sites which include labia minora in females, oral mucosa, conjunctiva, urethra, cheeks, and epiglottis have been described in literature.<ref name="pmid24792459">{{cite journal| author=Adégbidi H, Atadokpèdé F, Dégboé B, Saka B, Akpadjan F, Yédomon H et al.| title=[Zoon's balanitis in circumcised and HIV infected man, at Cotonou (Benin)]. | journal=Bull Soc Pathol Exot | year= 2014 | volume= 107 | issue= 3 | pages= 139-41 | pmid=24792459 | doi=10.1007/s13149-014-0359-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24792459 }}</ref>
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| {| class="wikitable"
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| !Clinical criteria in diagnosing Zoon balanitis <ref name="pmid172415662" />
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| |-
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| |Shiny, erythematous patches on the glans, prepuce, or both
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| |-
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| |Lesion present for > 3months
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| |-
| |
| |Absence of lesion suggestive of Lichen planus, psoriasis elsewhere on the body
| |
| |-
| |
| |Poor response to topical therapies
| |
| |-
| |
| |Absence of concurrent infections which are ruled out after performing tzanck, potassium hydroxide, gram stain, and VDRL test.
| |
| |}
| |
| ===Laboratory findings===
| |
| {| class="wikitable"
| |
| ! colspan="2" |
| |
| |-
| |
| |Reflectance confocal microscopy
| |
| |A nucleated honeycomb pattern and vermicular vessels is a clue for benign inflammatory genital skin disease<ref name="pmid233254222">{{cite journal| author=Arzberger E, Komericki P, Ahlgrimm-Siess V, Massone C, Chubisov D, Hofmann-Wellenhof R| title=Differentiation between balanitis and carcinoma in situ using reflectance confocal microscopy. | journal=JAMA Dermatol | year= 2013 | volume= 149 | issue= 4 | pages= 440-5 | pmid=23325422 | doi=10.1001/jamadermatol.2013.2440 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23325422 }}</ref>
| |
| |-
| |
| |Dermoscopy
| |
| |Focal/diffuse orange-yellowish structure, less areas representing hemosiderin deposition, curved vessels due to epidermal thinning helps in distinguishing ZB from carcinoma in situ.<ref name="pmid266707162">{{cite journal| author=Errichetti E, Lacarrubba F, Micali G, Stinco G| title=Dermoscopy of Zoon's plasma cell balanitis. | journal=J Eur Acad Dermatol Venereol | year= 2016 | volume= 30 | issue= 12 | pages= e209-e210 | pmid=26670716 | doi=10.1111/jdv.13538 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26670716 }}</ref>
| |
| |}
| |
| ==Treatment==
| |
| Therapy focuses on prevention of disease progression.[30]
| |
|
| |
| Shelley reported some success with long-term antibiotic therapy. However, relapses were seen upon stopping treatment.[31]
| |
|
| |
| Some success has been reported with topical steroids,[32] when scarring is minimal,[33] though some have found this ineffectual.[34]
| |
|
| |
| Moderate therapeutic results have been reported using etretinate.[35]
| |
|
| |
| Some success has been reported in the use of carbon dioxide laser therapy.[36][37]
| |
|
| |
| Many authors report that circumcision is the treatment of choice,[9][2][38] with modifications if necessary.[39] Pasieczny suggests testosterone ointment, however.[40]
| |
|
| |
| Glansectomy may be required.[9]
| |
|
| |
| Currently, topical steriods are the most commonly used and most effective medication for the treatment of the adverse skin changes associated with BXO. Patients with urethral stricture disease associated with BXO are generally best managed with surgery to relieve the obstruction. Although urethral dilation is a treatment option, this treatment generally offers only temporary relief of the blockage and a complication of dilations can be stricture progression. The best treatment of urethral stricture treatment options are extended meatotomy (an open incision of the urethra) for short strictures and staged tissue transfer urethroplasty, a surgery to reconstruct the urethra using grafts such as buccal mucosa from inside the cheek.
| |
| === General measures ===
| |
| Good hygiene which include retracting the foreskin regularly and gentle cleansing of entire glans, preputial sac, and foreskin were found effective in treating the diseases.<ref name="pmid24828553">{{cite journal| author=Edwards SK, Bunker CB, Ziller F, van der Meijden WI| title=2013 European guideline for the management of balanoposthitis. | journal=Int J STD AIDS | year= 2014 | volume= 25 | issue= 9 | pages= 615-26 | pmid=24828553 | doi=10.1177/0956462414533099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24828553 }}</ref>
| |
|
| |
| ===Medical Therapy===
| |
| {| class="wikitable"
| |
| ! colspan="3" |Various medical managements for Zoons balanitis
| |
| !
| |
| |-
| |
| !
| |
| !Drug dosage
| |
| !Effectiveness
| |
| !
| |
| |-
| |
| | rowspan="2" |Topical steroids
| |
| |Saline compresses containing 1% hydrocortisone/0.02% betamethason+/-17-valerate/0.05% betamethasone dipropionate
| |
| |3 out of 6 patients responded
| |
| |
| |
| |-
| |
| |Oxytetracycline 3%, nystatin 100,00(units/g), and clobetasone butyrate 0.05% applied until complete resolution was observed
| |
| |All patients responded, but 3 out of 10 patients had recurrences
| |
| |
| |
| |-
| |
| |Topical calineurin
| |
| |Tacrolimus ointment 0.1% twice daily
| |
| |Complete remission after 4 weeks of treatment was observed in 9 patients , with no relapse observed after 3 months of follow up
| |
| |
| |
| |-
| |
| |Topical Pimecrolimus
| |
| |Pimecrolimus cream 1% twice daily
| |
| |Improvement is observed after 2 months of treatment with no relapse observed
| |
| |
| |
| |-
| |
| | rowspan="2" |Topical Imiquimod
| |
| |5% imiquimod cream, 3 times a week for 4 months with multiple periods without treatment
| |
| | rowspan="2" |Complete resolution can be found after 4-12 weeks of treatment, with no cases of relapse observed
| |
| |
| |
| |-
| |
| |5% imiquimod cream, 3 times a week for 12 months without any interruption
| |
| |
| |
| |}
| |
|
| |
| === Surgery ===
| |
| {| class="wikitable"
| |
| ! colspan="4" |Various surgical modalities for Zoon's balanitis
| |
| |-
| |
| |Circumcision
| |
| |Lesion disappear by 5-6 weeks after procedure, with no relapse observed
| |
| |
| |
| |
| |
| |-
| |
| |Carbon dioxide lesion
| |
| |Complete resolution in 3 months, with no relapse observed in following 5 years of follow up
| |
| |
| |
| |
| |
| |-
| |
| |Yag laser
| |
| |Complete clearance is seen patients within 2-3 weeks, with no relapse observed in following 30 months of follow up
| |
| |
| |
| |
| |
| |-
| |
| |PDT
| |
| |Lesion healed completely after an average 2.75 PDT sessions, with no relapse observed in following 1 year of follow up
| |
| |
| |
| |
| |
| |}
| |
|
| |
| === Photodynamic therapy ===
| |
| Photodynamic therapy, 5-aminolaevulinic acid (ALA) or methyl aminolevulinate (MAL), has been proposed for refractory lesions of ZB. ALA-PDT seems to be slightly better than MAL-PDT, with no long-term side effects observed.<ref name="pmid22693017">{{cite journal| author=Pinto-Almeida T, Vilaça S, Amorim I, Costa V, Alves R, Selores M| title=Complete resolution of Zoon balanitis with photodynamic therapy--a new therapeutic option? | journal=Eur J Dermatol | year= 2012 | volume= 22 | issue= 4 | pages= 540-1 | pmid=22693017 | doi=10.1684/ejd.2012.1779 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22693017 }}</ref>
| |
|
| |
| === Miscellaneous therapies ===
| |
| Once-daily application fusidic acid cream for 8-16 weeks was effective in suppression and cure of ZB.<ref name="pmid1401323">{{cite journal| author=Petersen CS, Thomsen K| title=Fusidic acid cream in the treatment of plasma cell balanitis. | journal=J Am Acad Dermatol | year= 1992 | volume= 27 | issue= 4 | pages= 633-4 | pmid=1401323 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1401323 }}</ref>
| |
|
| |
| ==Prevention==
| |
| There is no known means of preventing BXO. However, one study reports that the data "suggest that circumcision prevents or protects against common infective penile dermatoses."<ref name="mallon2000" />
| |
|
| |
| ===Primary Prevention===
| |
| Circumcision in males can help in reducing risk of having ZB.<ref name="pmid278909453">{{cite journal| author=Dayal S, Sahu P| title=Zoon balanitis: A comprehensive review. | journal=Indian J Sex Transm Dis | year= 2016 | volume= 37 | issue= 2 | pages= 129-138 | pmid=27890945 | doi=10.4103/0253-7184.192128 | pmc=5111296 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27890945 }}</ref>
| |
|
| |
| ===Secondary prevention===
| |
| There is no secondary prevention measures.
| |
|
| |
| ==References==
| |
| {{Reflist|2}}
| |
| [[Category:Balanitis]]
| |
| [[Category:Infectious diseases]]
| |
| {{Lipopedia}}
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| {{WikiDoc Sources}}
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