Zoon's balanitis: Difference between revisions

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{{SI}}
{{CMG}}{{AE}}{{VD}}


{{CMG}}{{AE}}{{VD}}
{{SK}} ZB, Plasma cell balanitis


{{SK}}Balanoposthite chronique circonscrite bénigne á plasmocytes, Balanitis chronica circumscripta plasmacellularis, ZB, Zoon's vulvitis, Plasma cell vulvitis, Vulvitis circumscripta plasmacellularis
==Overview==
==Overview==
Zoon's balanitis is a rare nonveneral idiopathic, chronic, benign inflammatory mucositis of genitalia. It was first described in the modern literature by Zoon, in 1952. The exact pathogenesis is not clearly known. It present as well circumscribed single or multiple, orange-red in colour with a characteristic glazed appearance and multiple pinpoint redder spots-"cayenne pepper spots" most commonly involving the glans penis.  
Zoon's balanitis is a rare non-veneral [[idiopathic]] [[chronic]] [[benign]] [[inflammatory]] [[mucositis]] of [[genitalia]]. In 1952, for the first time in medical literature, Zoon recognized a distinct entity in patients with chronic [[balanitis]],and named it has balanoposthite chronique circonscrite bénigne á plasmocytes or balanitis chronica circumscripta plasmacellularis.<ref name="pmid1297957622" /> The exact [[pathogenesis]] of Zoon's [[balanitis]] is not clearly known. Patients with Zoon's [[balanitis]] presents with well circumscribed single or multiple orange-red in colour lesions with characteristic glazed appearance and multiple pinpoint redder spots "cayenne pepper spots" most commonly involving [[glans penis]]. [[Diagnosis]] of Zoon's [[balanitis]] is confirmed by [[biopsy]]. Management of Zoon's [[balanitis]] includes both [[medical]] and [[Surgery|surgical]] modalities.
 
==Historical Perspective==
==Historical Perspective==
*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>
*In 1952, for the first time in medical literature, Zoon recognized a distinct entity in patients with chronic [[balanitis]], named it has balanoposthite chronique circonscrite bénigne á plasmocytes” or “balanitis chronica circumscripta plasmacellularis.<ref name="pmid1297957622">{{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>
*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>
*In 1954, Garnier reported similar lesions in [[vulva]].<ref name="pmid707398422">{{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>
*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>
*In 1956, Nikolowski described identical [[lesions]] in oral [[mucosa]].<ref name="pmid1334078922">{{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>
*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>
*In 1963, Kortnig described idential lesions in [[conjunctiva]].<ref name="pmid1409811922">{{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>
==Classification==
==Classification==
There is no established classification system for Zoon balanitis.
There is no established classification system for Zoon's [[balanitis]].
==Pathophysiology==
==Pathophysiology==
===Pathogenesis===
===Pathogenesis===
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>
The exact [[pathogenesis]] of Zoon's [[balanitis]] is not clearly known, but following theories have been postulated:<ref name="pmid1131997022">{{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>
*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.
*Accumulation of [[epithelial]] debris and secretions between [[foreskin]] and [[penis]] proximal to [[coronal sulcus]], [[smegma]], poor [[genital]] hygiene, repeated local [[infections]], and hot and humid weather results in chronic physical irritation or sub-clinical [[trauma]]. Chronic physical irritation or sub-clinical [[trauma]] in-turn results in [[skin]] lesions along the line of [[trauma]].
*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>
*Chronic [[infection]] with [[Mycobacterium smegmatis]] and [[human papillomaviruses]] (HPV) was found to be associated with development of Zoon's [[balanitis]].<ref name="pmid1558856022">{{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>
*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>
====Histopathology====
====Histopathology====
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>
Zoon's [[balanitis]] has distinctive [[histopathological]] features, which include:<ref name="pmid12454596222">{{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>
====Epidermal====
====Epidermal====
*Epidermal changes include, early thickening, acanthosis and parakeratosis of epidermis, which is followed by atrophy, erosions and spongiosis.
*[[Epidermal]] changes include early thickening with acanthosis and parakeratosis of [[epidermis]], which is followed by [[atrophy]], erosion and spongiosis of [[epidermis]].
*Scattered neutrophils can be present in superficial erosions of the epidermis.
*Scattered [[neutrophils]] may be found in superficial erosions of the [[epidermis]].
*Spongiosis accentuation occurs in the lower half of the spinous zone.
*Spongiosis accentuation may occur in the lower half of spinous zone.
*Subepidermal clefts, necrotic keratinocytes, and lozenge keratinocytes can be seen in the late stages of ZB.
*Subepidermal clefts, [[necrotic]] [[keratinocytes]], and [[lozenge]] [[keratinocytes]] may be seen in the later stages of Zoon's balanitis.
====Dermal====
====Dermal====
*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.
*[[Dermal]] changes include patchy lichenoid infiltrate of [[lymphocytes]] and [[Plasma cell|plasma cells]] in [[papillary]] [[dermis]], which are replaced by [[neutrophils]], [[eosinophils]], [[lymphocytes]] and [[erythrocytes]].
*Dermal  vascular dilatation with singular vertical or oblique orientation of proliferated individual vessels, is a characteristic feature of ZB.
*[[Dermal]] [[vascular]] dilatation with singular vertical or oblique orientation of proliferated individual vessels is a characteristic feature of Zoon's [[balanitis]].
*In the later stages, upper dermis shows fibrosis which correlates well with subepidermal clefts, epidermal atrophy, and plasma cell infiltrates.
*In the later stages, upper [[dermis]] may show [[fibrosis]] which correlates well with sub-epidermal [[clefts]], [[epidermal]] [[atrophy]], and [[plasma cell]] infiltrates.
==Epidemiology and Demographics==
==Epidemiology and Demographics==
Epidemiological and Demographic data of Zoon balanitis is scare.
There are no comprehensive studies studying the [[epidemiology]] and [[demographics]] of Zoon's disease in general population. A recent study has reported that out of 226 patients examined in a [[genitourinary medicine]] clinic over a period of 3 years, about 26(10%) of patients were diagnosed with Zoon's [[balanitis]].<ref name="pmid25294843">{{cite journal| author=Pearce J, Fernando I| title=The value of a multi-specialty service, including genitourinary medicine, dermatology and urology input, in the management of male genital dermatoses. | journal=Int J STD AIDS | year= 2015 | volume= 26 | issue= 10 | pages= 716-22 | pmid=25294843 | doi=10.1177/0956462414552695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25294843  }}</ref>
 
==Screening==
==Screening==
There is no established screening guidelines for Zoon balanitis
There is no established screening guidelines for Zoon's [[balanitis]].
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural history===
===Natural history===
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>  
If left untreated, patients with Zoon's [[balanitis]] may develop [[pain]], [[phimosis]] and [[paraphimosis]]. Studies have reported that there could be an increased risk of transformation of these lesions into [[squamous cell carcinoma]].<ref name="pmid278909454">{{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>
 
===Complications===
===Complications===
Complications of Zoon balanitis include:
[[Complications]] of Zoon's [[balanitis]] include:
* Phimosis  
*[[Phimosis]]
* Paraphimosis
*[[Paraphimosis]]
 
*Risk of transformation into [[malignancy]]([[Squamous cell carcinoma]])<ref name="pmid278909454" />
===Prognosis===
===Prognosis===
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>  
[[Prognosis]] is usually good with treatment.<ref name="pmid2789094522">{{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>
 
==Diagnosis==
==Diagnosis==
Diagnosis is made on by obtaining detailed history, physical examination and reflectance confocal microscopy/dermoscopy findings:
===History and symptoms===
===History and symptoms===
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>
Patients with Zoon's [[balanitis]] could present with asymptomatic or symptomatic lesions with:<ref name="pmid2482855322">{{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>
*Itching (pruritus) of the genitalia.
*[[Itching]] ([[pruritis]]) in the [[genitalia]] region
*Discomfort in urination(dysuria)
*Discomfort in [[urination]]([[dysuria]])
*Pain in the gential region
*Pain in the [[genital]] region
*blood stain discharge
*[[Blood]] stain discharge from the lesions
*Difficult or painful sexual intercourse
*Difficult or painful [[sexual]] [[intercourse]]
===Physical examination===
===Physical examination===
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>
Characteristic lesions seen in Zoon's [[balanitis]] are:<ref name="pmid1558856022" /><ref name="pmid1724156622">{{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>
* 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.
*Well circumscribed single or multiple, orange-red in colour [[lesions]] with 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 affecting the [[glans penis]]. Inner surface of [[prepuce]] and [[coronal sulcus]] may also be involved.
* 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>
*Though uncommon, lesions of Zoon's [[balanitis]] may also involve other sites which include [[labia minora]] in females, [[oral]] [[mucosa]], [[conjunctiva]], [[urethra]], [[cheeks]], and [[epiglottis]].<ref name="pmid247924592">{{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>
{| class="wikitable"
'''Clinical criteria for diagnosing Zoon's balanitis''' include the following:<ref name="pmid1724156622" />
!Clinical criteria in diagnosing Zoon balanitis <ref name="pmid172415662" />
* Shiny, [[erythematous]] patches on the [[glans]], [[prepuce]]<nowiki/>or both
|-
* [[Lesions]] present for more than 3 months
|Shiny, erythematous patches on the glans, prepuce, or both
* Absence of [[lesions]] which are suggestive of [[Lichen planus]] or [[psoriasis]] elsewhere on the body
|-
* Poor response to [[topical]] therapies
|Lesion present for > 3months
* Absence of concurrent [[infections]] which are ruled out after performing [[Tzanck test|tzanck]], [[potassium hydroxide]], [[gram stain]] and [[VDRL]] test
|-
 
|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===
===Laboratory findings===
{| class="wikitable"
[[Laboratory|Laboratory findings]] in Zoon's [[balanitis]] include:<ref name="pmid2332542222">{{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><ref name="pmid2667071622">{{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>
! colspan="2" |
 
|-
'''Reflectance confocal microscopy'''
|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>
A nucleated honeycomb pattern and vermicular [[vessels]] is a clue for [[benign]] [[inflammatory]] [[genital]] [[skin]] disease
|-
 
|Dermoscopy
'''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>
 
|-
Focal/diffuse orange-yellowish structure with fewer areas representing [[hemosiderin]] deposition and curved vessels due to [[epidermal]] thinning help in distinguishing ZB from [[carcinoma in situ]].
|Biopsy
 
|Epidermis: Epidermis thickening which is followed by epidermal atrophy, at times with erosions.Dermis: Plasma cell infiltrate with haemosiderin and extravasated red blood cells.  
==== Biopsy ====
|}
 
===== Epidermis =====
[[Epidermal]] thickening which is followed by [[epidermal]] [[atrophy]], at times with erosions
 
'''Dermis'''
 
[[Plasma cell]] infiltrate with [[haemosiderin]] and extravasated [[red blood cells]].
 
==Treatment==
==Treatment==
Management of Zoon's [[balanitis]] includes general measures, medical and surgical modalities:<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><ref name="pmid248285533" /><ref name="pmid226930172">{{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>


=== General measures ===
===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>
Good hygiene which include retracting the [[foreskin]] regularly and gentle cleansing of entire [[glans]], preputial sac, and [[foreskin]] were found effective in treating [[Balanitis]] in general.<ref name="pmid248285533">{{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===
===Medical Therapy===
{| class="wikitable"
{| class="wikitable"
! colspan="3" |Various medical managements for Zoon's balanitis
! colspan="2" |Medical modalities for treating  Zoon's balanitis
|-
|-
!
!Drugs
!Drug dosage
!Drug dosage
!Effectiveness
|-
|-
| rowspan="2" |Topical steroids
| rowspan="2" |[[Topical steroid|Topical steroids]]
|Saline compresses containing 1% hydrocortisone/0.02% betamethason+/-17-valerate/0.05% betamethasone dipropionate
|Saline compresses containing 1% [[hydrocortisone]]/0.02% [[betamethasone]]+/-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
|[[Oxytetracycline]] 3%, [[nystatin]] 100,00(units/g), and [[Clobetasone|clobetasone butyrate]] 0.05% applied until complete resolution was observed
|All patients responded, but 3 out of 10 patients had recurrences
|-
|-
|Topical calineurin
|Topical [[calcineurin]]
|Tacrolimus ointment 0.1% twice daily
|[[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
|Topical [[Pimecrolimus]]
|Pimecrolimus cream 1% twice daily
|[[Pimecrolimus]] cream 1% twice daily
|Improvement is observed after 2 months of treatment with no relapse observed
|-
|-
| rowspan="2" |Topical Imiquimod
| rowspan="2" |Topical [[Imiquimod]]
|5% imiquimod cream, 3 times a week for 4 months with multiple periods without treatment
|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
|5% [[imiquimod]] cream, 3 times a week for 12 months without any interruption
|}
|}
 
===Surgery===
=== Surgery ===
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Various surgical modalities for Zoon's balanitis
! colspan="2" |Surgical modalities for treating Zoon's balanitis
|-
|-
|Circumcision
|'''Procedure'''
|Lesion disappear by 5-6 weeks after procedure, with no relapse  observed 
|'''Follow-up'''
|-
|-
|Carbon dioxide lesion
|[[Circumcise|Circumcision]]
|Complete resolution in 3 months, with no relapse observed in following 5 years of follow up
|Lesion disappear by 5-6 weeks after procedure, with no relapse observed
|-
|Carbon dioxide laser
|Complete resolution in 3 months, with no relapse observed in following 5 years of follow up
|-
|-
|Yag laser
|Yag laser
|Complete clearance is seen patients within 2-3 weeks, with no relapse observed in following 30 months of follow up
|Complete clearance is seen patients within 2-3 weeks, with no [[relapse]] observed in following 30 months of follow up
|-
|-
|PDT
|PDT(Photodynamic therapy)
|Lesion healed completely after an average 2.75 PDT sessions, with no relapse observed in following 1 year of follow up
|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==
==Prevention==
===Primary Prevention===
===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>
There is no established [[primary prevention]] measures for preventing of Zoon's [[balanitis]].


===Secondary prevention===
===Secondary prevention===
There is no secondary prevention measures.  
There is no established [[secondary prevention]] measures for Zoon's [[balanitis]].
 
==References==
==References==
{{Reflist|2}}
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Latest revision as of 21:30, 10 April 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Synonyms and keywords: ZB, Plasma cell balanitis

Overview

Zoon's balanitis is a rare non-veneral idiopathic chronic benign inflammatory mucositis of genitalia. In 1952, for the first time in medical literature, Zoon recognized a distinct entity in patients with chronic balanitis,and named it has balanoposthite chronique circonscrite bénigne á plasmocytes or balanitis chronica circumscripta plasmacellularis.[1] The exact pathogenesis of Zoon's balanitis is not clearly known. Patients with Zoon's balanitis presents with well circumscribed single or multiple orange-red in colour lesions with characteristic glazed appearance and multiple pinpoint redder spots "cayenne pepper spots" most commonly involving glans penis. Diagnosis of Zoon's balanitis is confirmed by biopsy. Management of Zoon's balanitis includes both medical and surgical modalities.

Historical Perspective

  • In 1952, for the first time in medical literature, Zoon recognized a distinct entity in patients with chronic balanitis, named it has balanoposthite chronique circonscrite bénigne á plasmocytes” or “balanitis chronica circumscripta plasmacellularis.[1]
  • In 1954, Garnier reported similar lesions in vulva.[2]
  • In 1956, Nikolowski described identical lesions in oral mucosa.[3]
  • In 1963, Kortnig described idential lesions in conjunctiva.[4]

Classification

There is no established classification system for Zoon's balanitis.

Pathophysiology

Pathogenesis

The exact pathogenesis of Zoon's balanitis is not clearly known, but following theories have been postulated:[5]

Histopathology

Zoon's balanitis has distinctive histopathological features, which include:[7]

Epidermal

Dermal

Epidemiology and Demographics

There are no comprehensive studies studying the epidemiology and demographics of Zoon's disease in general population. A recent study has reported that out of 226 patients examined in a genitourinary medicine clinic over a period of 3 years, about 26(10%) of patients were diagnosed with Zoon's balanitis.[8]

Screening

There is no established screening guidelines for Zoon's balanitis.

Natural History, Complications, and Prognosis

Natural history

If left untreated, patients with Zoon's balanitis may develop pain, phimosis and paraphimosis. Studies have reported that there could be an increased risk of transformation of these lesions into squamous cell carcinoma.[9]

Complications

Complications of Zoon's balanitis include:

Prognosis

Prognosis is usually good with treatment.[10]

Diagnosis

History and symptoms

Patients with Zoon's balanitis could present with asymptomatic or symptomatic lesions with:[11]

Physical examination

Characteristic lesions seen in Zoon's balanitis are:[6][12]

Clinical criteria for diagnosing Zoon's balanitis include the following:[12]

Laboratory findings

Laboratory findings in Zoon's balanitis include:[14][15]

Reflectance confocal microscopy

A nucleated honeycomb pattern and vermicular vessels is a clue for benign inflammatory genital skin disease

Dermoscopy

Focal/diffuse orange-yellowish structure with fewer areas representing hemosiderin deposition and curved vessels due to epidermal thinning help in distinguishing ZB from carcinoma in situ.

Biopsy

Epidermis

Epidermal thickening which is followed by epidermal atrophy, at times with erosions

Dermis

Plasma cell infiltrate with haemosiderin and extravasated red blood cells.

Treatment

Management of Zoon's balanitis includes general measures, medical and surgical modalities:[16][17][18]

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 Balanitis in general.[17]

Medical Therapy

Medical modalities for treating Zoon's balanitis
Drugs Drug dosage
Topical steroids Saline compresses containing 1% hydrocortisone/0.02% betamethasone+/-17-valerate/0.05% betamethasone dipropionate
Oxytetracycline 3%, nystatin 100,00(units/g), and clobetasone butyrate 0.05% applied until complete resolution was observed
Topical calcineurin Tacrolimus ointment 0.1% twice daily
Topical Pimecrolimus Pimecrolimus cream 1% twice daily
Topical Imiquimod 5% imiquimod cream, 3 times a week for 4 months with multiple periods without treatment
5% imiquimod cream, 3 times a week for 12 months without any interruption

Surgery

Surgical modalities for treating Zoon's balanitis
Procedure Follow-up
Circumcision Lesion disappear by 5-6 weeks after procedure, with no relapse observed
Carbon dioxide laser 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(Photodynamic therapy) Lesion healed completely after an average 2.75 PDT sessions, with no relapse observed in following 1 year of follow up

Prevention

Primary Prevention

There is no established primary prevention measures for preventing of Zoon's balanitis.

Secondary prevention

There is no established secondary prevention measures for Zoon's balanitis.

References

  1. 1.0 1.1 ZOON JJ (1952). "[Chronic benign circumscript plasmocytic balanoposthitis]". Dermatologica. 105 (1): 1–7. PMID 12979576.
  2. Sonnex TS, Dawber RP, Ryan TJ, Ralfs IG (1982). "Zoon's (plasma-cell) balanitis: treatment by circumcision". Br J Dermatol. 106 (5): 585–8. PMID 7073984.
  3. NIKOLOWSKI W, WIEHL R (1956). "[Not Available]". Arch Klin Exp Dermatol. 202 (4): 347–57. PMID 13340789.
  4. KORTING GW, THEISEN H (1963). "[CIRCUMSCRIBED PLASMA CELL BALANOPOSTHITIS AND CONJUNCTIVITIS IN THE SAME PATIENT]". Arch Klin Exp Dermatol. 217: 495–504. PMID 14098119.
  5. Porter WM, Bunker CB (2001). "The dysfunctional foreskin". Int J STD AIDS. 12 (4): 216–20. PMID 11319970.
  6. 6.0 6.1 Pastar Z, Rados J, Lipozencić J, Skerlev M, Loncarić D (2004). "Zoon plasma cell balanitis: an overview and role of histopathology". Acta Dermatovenerol Croat. 12 (4): 268–73. PMID 15588560.
  7. Weyers W, Ende Y, Schalla W, Diaz-Cascajo C (2002). "Balanitis of Zoon: a clinicopathologic study of 45 cases". Am J Dermatopathol. 24 (6): 459–67. PMID 12454596.
  8. Pearce J, Fernando I (2015). "The value of a multi-specialty service, including genitourinary medicine, dermatology and urology input, in the management of male genital dermatoses". Int J STD AIDS. 26 (10): 716–22. doi:10.1177/0956462414552695. PMID 25294843.
  9. 9.0 9.1 Dayal S, Sahu P (2016). "Zoon balanitis: A comprehensive review". Indian J Sex Transm Dis. 37 (2): 129–138. doi:10.4103/0253-7184.192128. PMC 5111296. PMID 27890945.
  10. Dayal S, Sahu P (2016). "Zoon balanitis: A comprehensive review". Indian J Sex Transm Dis. 37 (2): 129–138. doi:10.4103/0253-7184.192128. PMC 5111296. PMID 27890945.
  11. Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  12. 12.0 12.1 Kumar B, Narang T, Dass Radotra B, Gupta S (2006). "Plasma cell balanitis: clinicopathologic study of 112 cases and treatment modalities". J Cutan Med Surg. 10 (1): 11–5. PMID 17241566.
  13. Adégbidi H, Atadokpèdé F, Dégboé B, Saka B, Akpadjan F, Yédomon H; et al. (2014). "[Zoon's balanitis in circumcised and HIV infected man, at Cotonou (Benin)]". Bull Soc Pathol Exot. 107 (3): 139–41. doi:10.1007/s13149-014-0359-4. PMID 24792459.
  14. Arzberger E, Komericki P, Ahlgrimm-Siess V, Massone C, Chubisov D, Hofmann-Wellenhof R (2013). "Differentiation between balanitis and carcinoma in situ using reflectance confocal microscopy". JAMA Dermatol. 149 (4): 440–5. doi:10.1001/jamadermatol.2013.2440. PMID 23325422.
  15. Errichetti E, Lacarrubba F, Micali G, Stinco G (2016). "Dermoscopy of Zoon's plasma cell balanitis". J Eur Acad Dermatol Venereol. 30 (12): e209–e210. doi:10.1111/jdv.13538. PMID 26670716.
  16. Dayal S, Sahu P (2016). "Zoon balanitis: A comprehensive review". Indian J Sex Transm Dis. 37 (2): 129–138. doi:10.4103/0253-7184.192128. PMC 5111296. PMID 27890945.
  17. 17.0 17.1 Edwards SK, Bunker CB, Ziller F, van der Meijden WI (2014). "2013 European guideline for the management of balanoposthitis". Int J STD AIDS. 25 (9): 615–26. doi:10.1177/0956462414533099. PMID 24828553.
  18. Pinto-Almeida T, Vilaça S, Amorim I, Costa V, Alves R, Selores M (2012). "Complete resolution of Zoon balanitis with photodynamic therapy--a new therapeutic option?". Eur J Dermatol. 22 (4): 540–1. doi:10.1684/ejd.2012.1779. PMID 22693017.

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