Sandbox:Inflammatory dermatosis

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

Overview

Inflammatory dermatosis 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.

• Please click here to know more about Zoon's Balanitis
• Please click here to know more about Balanitis xerotica obliterans
• Please click here to know more about Lichen sclerosus
• Please click here to know more about Lichen planus
• Please click here to know more about Psoriasis
• Please click here to know more about Circinate balanitits
• Please click here to know more about Eczema
• Please click here to know more about Seborrhoeic dermatitis
• Please click here to know more about Fixed drug eruption

Distinguishing clincal features, diagnosis, management of balanitis due to inflammatory dermatosis

Distinguishing clincal features, diagnosis, management of balanitis due to inflammatory dermatosis, include:

2013 European guideline for the management of balanoposthitis
	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 rarely blisters and ulceration may be present .	Biopsy Epidermis: Thickened epidermis which then becomes atrophic with follicular hyperkeratosis. Dermis: Dermal hyalinisation 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 (pimecrolimus applied twice daily, 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 ot 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	Purlish lesions on the Presence of lichen planus lesions elsewhere in body	Biopsy 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 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	In atypical cases or cases which do not resolve with with treatment penile biopsy should be performed.
Psoriasis	Circumcised male Red scaly plaques Uncircumcised Patches appear red and glazed Scaling is lost	Biopsy Parakeratosis and acanthosis with elongation of rete ridges. Collections of neutrophils in the epidermis may be present.	Moderate potency topical steroids( antibiotic and antifungal). 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 Reiters syndrome	Biopsy 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, such as urethritis, gastrointestinal disease and arthritis STD's: Sexual partners should be tested for STD's.		Follow up may be needed in persistent symptomatic lesions.
Eczema	Eczema may present has mild non-specific erythema to wide spread edema on penis .	Biopsy 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 Hydrocortisone 1% can be applied until resolution of symptoms	Follow up is usually not required.
Seborrhoeic dermatitis	Mild itch or redness		Antifungal cream with a mild to moderate steroid.	Oral azole itraconazole Oral tetracycline Oral terbinafine may be effective43
Fixed drug eruption	Well demarcated and erythematous lesions. Lesion may be bullous and may undergo subsequent ulceration	Biopsy 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 persistence.	Failure to respond to maximal topical steroid and antifungal treatments. Non-specific histology on biopsy.	Circumcision is curative.