Zoon's balanitis: Difference between revisions

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{{SK}}Balanoposthite chronique circonscrite bénigne á plasmocytes, Balanitis chronica circumscripta plasmacellularis, ZB, Zoon's vulvitis, Plasma cell vulvitis, Vulvitis circumscripta plasmacellularis
{{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 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.
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 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 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 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 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 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 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 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>
*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's balanitis.
There is no established classification system for Zoon's [[balanitis]].
==Pathophysiology==
==Pathophysiology==
===Pathogenesis===
===Pathogenesis===
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>
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>
*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.
*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'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>
*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>
====Histopathology====
====Histopathology====
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>
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 with acanthosis and parakeratosis of [[epidermis]], which is followed by [[atrophy]], erosion and spongiosis of [[epidermis]].
*[[Epidermal]] changes include early thickening with acanthosis and parakeratosis of [[epidermis]], which is followed by [[atrophy]], erosion and spongiosis of [[epidermis]].
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*Subepidermal clefts, [[necrotic]] [[keratinocytes]], and [[lozenge]] [[keratinocytes]] may be seen in the later stages of Zoon's balanitis.
*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 cell|plasma cells]] in [[papillary]] [[dermis]], which are replaced by  [[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 Zoon's Balanitis.
*[[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]] may show [[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==
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>
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's 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, patients with Zoon's balanitits 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>
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's balanitis include:
[[Complications]] of Zoon's [[balanitis]] include:
*[[Phimosis]]
*[[Phimosis]]
*[[Paraphimosis]]
*[[Paraphimosis]]
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==Diagnosis==
==Diagnosis==
===History and symptoms===
===History and symptoms===
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>
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) in the [[genitalia]] region
*[[Itching]] ([[pruritis]]) in the [[genitalia]] region
*Discomfort in [[urination]]([[dysuria]])
*Discomfort in [[urination]]([[dysuria]])
*Pain in the [[genital]] region
*Pain in the [[genital]] region
*Blood stain discharge from the lesions
*[[Blood]] stain discharge from the lesions
*Difficult or painful [[sexual]] [[intercourse]]
*Difficult or painful [[sexual]] [[intercourse]]
===Physical examination===
===Physical examination===
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>
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 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.
*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'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>
*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>
'''Clinical criteria for diagnosing Zoon's balanitis''' include the following:<ref name="pmid1724156622" />
'''Clinical criteria for diagnosing Zoon's balanitis''' include the following:<ref name="pmid1724156622" />
* Shiny, erythematous patches on the [[glans]], [[prepuce]], or both
* Shiny, [[erythematous]] patches on the [[glans]], [[prepuce]]<nowiki/>or both
* [[Lesions]] present for > 3 months
* [[Lesions]] present for more than 3 months
* Absence of lesions which are suggestive of [[Lichen planus]] or [[psoriasis]] elsewhere on the body
* Absence of [[lesions]] which are suggestive of [[Lichen planus]] or [[psoriasis]] elsewhere on the body
* Poor response to topical therapies
* Poor response to [[topical]] therapies
* Absence of concurrent [[infections]] which are ruled out after performing [[Tzanck test|tzanck]], [[potassium hydroxide]], [[gram stain]], and [[VDRL]] test
* Absence of concurrent [[infections]] which are ruled out after performing [[Tzanck test|tzanck]], [[potassium hydroxide]], [[gram stain]] and [[VDRL]] test


===Laboratory findings===
===Laboratory findings===
[[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>
[[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>


'''Reflectance confocal microscopy'''
'''Reflectance confocal microscopy'''


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


'''Dermoscopy'''
'''Dermoscopy'''
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==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>  
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===
Line 132: Line 132:
==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
There is no established primary prevention measures for preventing of Zoon's balanitits.
There is no established [[primary prevention]] measures for preventing of Zoon's [[balanitis]].


===Secondary prevention===
===Secondary prevention===
There is no established secondary prevention measures for Zoon's balanitis.
There is no established [[secondary prevention]] measures for Zoon's [[balanitis]].
==References==
==References==
{{Reflist|2}}{{WikiDoc Help Menu}} {{WikiDoc Sources}}
{{Reflist|2}}{{WikiDoc Help Menu}} {{WikiDoc Sources}}
[[Category:Balanitis]]
[[Category:Balanitis]]
[[Category:Infectious diseases]]
[[Category:Infectious diseases]]

Revision as of 19:22, 30 March 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:Balanoposthite chronique circonscrite bénigne á plasmocytes, Balanitis chronica circumscripta plasmacellularis, ZB, Zoon's vulvitis, Plasma cell vulvitis, Vulvitis circumscripta plasmacellularis

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 less areas representing hemosiderin deposition and curved vessels due to epidermal thinning helps 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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