Inflammatory dermatoses

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

• Please click here to know more about Zoon's Balanitis
• Please click here to know more about Balanitis xerotica obliterans

Overview

Inflammatory dermatoses of penis represents a group of inflammatory conditions which effect the penis causing balanitis. Pathogenesis, risk factors, clinical features, laboratory findings and treatment vary from condition to condition.

Distinguishing clinical features, diagnosis, and management inflammatory dermatoses of penis

Distinguishing clinical features, diagnosis, and management of balanitis due to inflammatory dermatoses, include:

Distinguishing clincal features, diagnosis, and management of balanitis due to inflammatory dermatosis
	Distinguishing clinical features shown on the penis	Diagnosis	Management
			Recommended regimen	Alternative regimens	Follow-up
Lichen sclerosus	White patches on glans, which may often involve prepuce Haemorrhagic vesicles, purpura with rare blisters and ulceration may be present	Biopsy of lesion Epidermis: Thickened epidermis which then becomes atrophic with follicular hyperkeratosis Dermis: Dermal hyalinization with loss of elastin fibers and underlying perivascular lymphocytic infiltrate	Ultrapotent topical steroids(e.g. clobetasol proprionate) applied once daily until remission, then gradually reduced. Intermittent use (e.g. once weekly) may be required to maintain remission. Secondary infection should be treated.	Although topical calcineurin inhibitors have been claimed to be efficacious, there is concern about the risk of malignancy Surgery is indicated when lesion are associated with phimosis and meatal stenosis. Surgical procedures include circumcision, meatotomy or urethroplasty. Circumcision is indicated for failed topical medical treatment.	Persistent requirement for topical treatment is an indication of circumcision. Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
Lichen planus	Purplish lesions on the penis Presence of lichen planus lesions elsewhere in body	Biopsy of lesion Epidermis Irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction Dermis: Band-like dermal infiltrate (mainly lymphocytic)	Moderate to ultrapotent topical steroids depending on severity	Topical and oral ciclosporin have been used for erosive disease. Circumcision: May be the treatment of choice for some cases of erosive lichen planus	Persistent requirement for topical treatment is an indication of circumcision. Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
Zoon’s (plasma cell) balanitis	Well-circumscribed orange-red glazed areas on the glans and foreskin. Multiple symmetrical pinpoint redder spots – ‘cayenne pepper spots.’	Biopsy of lesion Epidermis: Epidermis thickening which is followed by epidermal atrophy, at times with erosions Dermis: Plasma cell infiltrate with haemosiderin and extravasated red blood cells	Circumcision Topical steroid preparations(Trimovate cream, applied once or twice daily) Hygiene measures	CO2 laser Topical tacrolimus can also be useful.	In atypical cases or cases which do not resolve with treatment, penile biopsy should be performed.
Psoriasis	Circumcised male Red scaly plaques Uncircumcised Patches appear red and glazed Scaling is lost	Biopsy of lesion Parakeratosis and acanthosis with elongation of rete ridges and collections of neutrophils in the epidermis may be present	Moderate potency topical steroids Emollients	Topical Vitamin D preparations (calcipotriol or calcitriol applied twice daily) Topical bethamethasone dipropionate/calcipotriol ointment may be well tolerated in treatment of anogenital psoriasis, but potent steroids may not be indicated Topical tacrolimus has been used in small studies but should not be used as first-line therapy Topical pimecrolimus can also be useful
Circinate balanitis	Greyish white areas on the glans These areas may coalesce to form ‘geographical’ areas with a white margin Usually associated with Reiter's syndrome	Biopsy of lesion Epidermis: Spongiform pustules in the upper epidermis	Screening for STIs. Syphilis can also give rise to similar features. Consider testing for HLAB27, a positive test can confirm a diagnosis and provide important information about the risk of associated disease conditions such as urethritis, gastrointestinal disease and arthritis STD's: Sexual partners should be tested for STD's.	STD's should be appropriately treated as per protocol Topical steroids like hydrocortisone/ triamcinolone, or combination of keratolytic agents likes 10% salicylic acid ointment with hydrocortisone 2.5% cream, and oral aspirin are effective Topical calcineurin inhibitors can also be useful	Follow up may be needed in persistent symptomatic lesions
Eczema	Eczema may present has mild non-specific erythema to wide spread edema of penis.	Biopsy of lesion Eczematous with spongiosis and non-specific inflammation	Patients should be advice to avoid precipitants(Soap) and apply emollients Hydrocortisone 1% applied once or twice daily until resolution of symptoms	Potent topical steroids combine with antifungal and antibiotics may be needed in florid cases	Follow up is usually not required.
Seborrhoeic dermatitis	Mild itch or redness		Anti-fungal cream with mild to moderate topical steroids.	Oral Itraconazole or Oral Tetracycline or Oral Terbinafine may be effective
Fixed drug eruption	Well demarcated and erythematous lesions. Lesion may be bullous and may undergo subsequent ulceration	Biopsy of lesion Hydropic degeneration of the basal layer Epidermal detachment and necrosis with pigmentary incontinence	Condition will settle without treatment Topical steroids – e.g. mild to moderate strength twice daily until resolution Rarely systemic steroids may be required if the lesions are severe
Non-specific balanoposthitis	Chronic symptomatic presentation with relapses and remissions or persistent	Failure to respond to maximal topical steroid and antifungal treatments. Non-specific histology on biopsy.	Circumcision is curative