Simultaneous Occurrence of Balanoposthitis Circumscripta Plasmacellularis Zoon, Phimosis and in Situ Carcinoma of the Penis: Case Report with An Unusual Ulcerated Polypoid Variant of Zoon's Disease and a Carcinoma in Situ of Reserve Cell Type

Zoon balanitis: not a distinct clinicopathological entity?

Zoon balanitis (ZB) was originally described in the 1950s in patients with clinical features resembling erythroplasia of Queyrat but with histology that demonstrated a plasma cell infiltrate without evidence of dysplasia. Subsequently, ZB has been extensively reported in the literature, reflecting widespread acknowledgement as an established distinct clinicopathological entity. However, its existence as such has been questioned, and there have been suggestions in the literature that ZB represents either a nonspecific irritant reaction pattern, or a part of the heterogeneous clinicopathological complex of male genital lichen sclerosus (MGLSc). In this study, the entire historical literature of published cases of ZB was subject to review to determine whether clinical or histological features of MGLSc had been present and been overlooked. In total, 101 papers were reviewed. Seventy-five contained images purporting to be of ZB. Images that were deemed to be of inadequate quality or to present uninformative anatomical views were excluded. The images in 66 papers were amenable to scrutiny; 98.5% of these images demonstrated clinical signs of MGLSc, such as adhesions, effacement of the coronal sulcus and the frenulum, tightening of the prepuce, constrictive posthitis, etiolation of the glans, lichenoid inflammation and sclerosis. These findings strongly suggest that ZB occurs in the vast majority of cases as a manifestation of MGLSc and that its recognition as a distinct clinicopathological entity should be questioned, if not discontinued.

Plasma Cell Balanitis Unresponsive to Topical Corticosteroids: Combined Efficacy of Tacrolimus and Emerging Evidence for Underrecognized Intrinsic Resistance to Corticosteroids

Plasma cell balanitis (PCB), also known as Zoon's balanitis, is a chronic, benign inflammatory dermatosis affecting the glans penis, mainly occurring in uncircumcised middle-aged men. Currently, there has been no recommended and standardized treatment. Topical corticosteroids are the most common first-line therapy in clinical practice but often account for the primary inefficacy relapse and adverse events, particularly in cases requiring long-term use due to the high transcutaneous absorption in the penile skin. A series of recent case reports may suggest topical calcineurin inhibitors as a promising alternative, offering significant improvement in corticosteroid-resistant cases. In this paper, we describe a 61-year-old uncircumcised male patient with a one-year history of asymptomatic erosive erythema on the penis, which was initially unresponsive to topical corticosteroids. Lesional skin biopsy histologically confirmed a diagnosis of plasma cell balanitis. Combined treatment of a preceding topical corticosteroid with 0.1% tacrolimus ointment led to a dramatic clinical response within two weeks of treatment, followed by almost complete resolution after six weeks. This approach enabled the maintenance of the treatment efficacy with a weak-potency corticosteroid throughout the clinical course. Recurrence occurred with reduced application frequency, but the daily use of the same regimen rapidly restored favorable disease control. We discuss the potential difficulty in managing PCB, with particular interest in the relatively high frequency of corticosteroid resistance in nearly half of the cases reported to date. This paper also updates the possible mechanisms of action and clinical benefits of topical calcineurin inhibitors in plasma cell biology.

Zoon's balanitis presenting as discrete polyp on glans penis

The diagnosis of genital dermatological conditions in males can be challenging and rely on physical examination and biopsy. This report describes an unusual case of Zoon's balanitis producing a discrete polyp on the glans penis, in addition to the classically described well-demarcated erythematous macule.

Balanitis circumscripta plasmacellularis Zoon

Die Balanitis plasmacellularis Zoon (BPZ), zuerst beschrieben von J. J. Zoon, ist eine chronische entzündliche Dermatose, die histologisch definiert ist anhand eines subepithelialen, lymphohistiozytären Infiltrates mit vielen Plasmazellen. Dabei wurden ein Spektrum epithelialer Veränderungen und eine variable Zusammensetzung des Infiltrates beschrieben. Dadurch unterscheidet sie sich von der Erythroplasie Queyrat, obwohl beide klinisch sehr ähnlich sind. An der BPZ erkranken vorwiegend ältere, nicht zirkumzidierte, heterosexuelle Männer. Klinisch typisch sind scharf umschriebene, rötlich-glänzende Rundherde an der Dorsalseite der Glans mit Übergang auf den Sulcus und das innere Präputialblatt. Erosionen und flache Infiltrate können hinzukommen. Der Verlauf ist chronisch mit sehr geringen Beschwerden, etwas erhöhte Empfindlichkeit wird oft genannt. Die Pathogenese ist unklar. Barrierestörung und Infektionen, unterhalten durch Feuchtigkeit, Mangel an Hygiene, Traumata und Irritationen, werden diskutiert. Dafür spricht auch das spontane Abheilen nach Zirkumzision oder lokalen Therapien mit Mucipirocin oder Fusidinsäure. Lokale Steroide sind ebenfalls – wie in unserem Fall – effektiv. Eine proaktive Therapie mit Tacrolimus-Salbe scheint eine Option. Die plasmazelluläre Entzündung ist nicht auf das männliche Genitale beschränkt, auch eine Vulvitis plasmacellularis ist beschrieben sowie der Befall nahezu aller weiteren Schleimhäute.