Photo Quiz

Persistent Penile Patch

Am Fam Physician. 2008 Nov 1;78(9):1081-1082.

An otherwise healthy 61-year-old man presented with a persistent rash on his penis. He said that the lesion may have slightly increased in size over the previous six months. He had no history of atopic dermatitis, psoriasis, lichen planus, or sexually transmitted diseases. The patient noted episodic tenderness. Previous use of low-potency topical corticosteroids did not alter the appearance of the rash.

On physical examination, a well-demarcated, pink-to-red plaque was noted on the distal penile shaft and coronal rim. Histopathologic examination revealed epidermal thinning, spongiosis, and a dense subepidermal infiltrate composed of plasma cells and neutrophils.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Balanitis xerotica obliterans.

B. Candidal balanitis.

C. Erythroplasia of Queyrat.

D. Syphilis.

E. Zoon balanitis.

Discussion

The answer is E: Zoon balanitis. Zoon balanitis, also known as balanitis circumscripta plasmacellularis or plasma cell balanitis, is an uncommon, benign, idiopathic, inflammatory penile dermatosis. The condition was first described in 1952 by J.J. Zoon.1 Zoon balanitis usually involves the glans penis and the prepuce, but it can occur on the balanopreputial fold and internal surface of the foreskin.2,3 It primarily occurs in middle-age or older men who are uncircumcised and presents on the dorsal surface of the penis, where more trauma tends to occur. This is also the site where maximal friction occurs during foreskin retraction. Numerous factors are thought to be involved in its etiology, including moisture, friction, repeated infections, and poor hygiene.2,4 Exposure of the mucosa to chronic irritation and a humid environment explains why Zoon balanitis is less common in circumcised men.2

Clinically, Zoon balanitis appears as a sharply demarcated, bright-red patch on the glans penis, coronal sulcus, or inner prepuce surface with frequent erosion and bleeding.4 Other features include pinpoint purpuric spotting and yellow discharge. Lesions are usually present for two to three years before diagnosis. Symptoms often include pruritus, burning, and tenderness.

Key histologic features of Zoon balanitis include epidermal thinning, possibly with some superficial erosion. Plasma cells and band-like infiltrates are present in the superficial dermis. Dilated capillaries and extravasated erythrocytes may also be present.2 More advanced lesions may include fibrosis and hemosiderin deposits in the upper dermis, as well as atrophy or complete loss of the overlying epidermis.4 Telangiectasia may occur in the inflammatory infiltrate. Suggested pathogenesis is a result of constant friction or trauma of the barely keratinized skin of the glans penis and inner prepuce surface in a moist environment. Compared with other areas, these regions of the penis are less resistant to mechanical forces. Irritation from moisture, friction, or external contacts and normal colonizing organisms that become pathogenic may be contributory.5

Prevention involves good personal hygiene and avoidance of potential irritants. Circumcision is the most effective long-term treatment because it reduces common infective penile dermatoses.6 Topical tacrolimus 0.1% ointment (Protopic), applied twice daily, has proved to be safe and effective.3 Other topical agents, such as antibacterials, corticosteroids, and antifungals, have had limited success and are not curative.2 Laser ablation (e.g., carbondioxide or erbium: YAG laser) has been an effective alternative to circumcision.2 Topical imiquimod 5% cream (Aldara) has recently been used successfully.7

Selected Differential Diagnosis of a Persistent Penile Patch

Condition Characteristics

Balanitis xerotica obliterans

Pruritic lesion on the genitals; may be treated with topical therapy; atrophic white patches or plaques on the glans penis and prepuce

Candidal balanitis

Diagnosed via potassium hydroxide testing to detect yeast; topical treatment is effective; erythema of the glans penis or foreskin

Erythroplasia of Queyrat

Precancerous lesion diagnosed with biopsy

Syphilis

Nonpainful lesion on the genitals with corresponding patient history

Zoon balanitis

Inflammatory penile dermatosis; often responds to topical therapy

Selected Differential Diagnosis of a Persistent Penile Patch

View Table

Selected Differential Diagnosis of a Persistent Penile Patch

Condition Characteristics

Balanitis xerotica obliterans

Pruritic lesion on the genitals; may be treated with topical therapy; atrophic white patches or plaques on the glans penis and prepuce

Candidal balanitis

Diagnosed via potassium hydroxide testing to detect yeast; topical treatment is effective; erythema of the glans penis or foreskin

Erythroplasia of Queyrat

Precancerous lesion diagnosed with biopsy

Syphilis

Nonpainful lesion on the genitals with corresponding patient history

Zoon balanitis

Inflammatory penile dermatosis; often responds to topical therapy

Address correspondence to Joshua E. Lane, MD, at jlanemd@gmail.com. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Zoon JJ. Chronic benign circumscript plasmocytic balanoposthitis. Dermatologica. 1952;105(1):1–7.

2. Retamar RA, Kien MC, Chouela EN. Zoon's balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol. 2003;42(4):305–307.

3. Santos-Juanes J, Sánchez del Río J, Galache C, Soto J. Topical tacrolimus: an effective therapy for Zoon balanitis. Arch Dermatol. 2004;140(12):1538–1539.

4. Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of Zoon: a clinicopathologic study of 45 cases. Am J Dermatopathol. 2002;24(6):459–467.

5. Albertini JG, Holck DE, Farley MF. Zoon's balanitis treated with erbium: YAG laser ablation. Lasers Surg Med. 2002;30(2):123–126.

6. Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol. 2000;136(3):350–354.

7. Nasca MR, De Pasquale R, Micali G. Treatment of Zoon's balanitis with imiquimod 5% cream. J Drugs Dermatol. 2007;6(5):532–534.

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