What is Balanitis Circumscripta Plasmacellularis?
Balanitis circumscripta plasmacellularis, also known as Zoon balanitis or plasma cell balanitis, is a long-term inflammatory condition of the foreskin, typically seen in men who are not circumcised. It’s believed to be caused by an improperly functioning foreskin that doesn’t cause any symptoms but shows noticeable signs. Dutch dermatologist Johannes Jacobus Zoon was the first to describe this noncancerous skin condition of the penis in 1952. This dysfunctional foreskin is thought to trap heat, body oils, and moisture, leaving the individual prone to ongoing infection and irritation. This is a non-threatening condition but needs to be distinguished from other similar conditions like sexually transmitted infections, reaction to medication, and other skin conditions. It also should not be confused with erythroplasia of Queyrat, which is a cancer-related disease. A comparable condition can also occur in women, called vulvitis circumscripta plasmacellularis.
What Causes Balanitis Circumscripta Plasmacellularis?
The actual cause of balanitis circumscripta plasmacellularis, a condition affecting the foreskin, is not entirely understood by medical experts. However, it’s commonly thought that the issue may be related to irritation from the accumulation of moisture, smegma (a natural secretion), and heat, when the foreskin doesn’t function ordinarily. The condition is generally absent in males who have been circumcised. This built-up occurs between two overpopulated, peeling, moist skin surfaces under poor hygiene conditions and repeated infections.
Two primary factors that contribute to this condition are the continual exposure to high humidity and persistent irritation. This is why the related sores, known as Zoon balanitis lesions, often improve significantly after circumcision. The foreskin’s impaired functionality may be linked to numerous concurrent conditions such as lichen sclerosus, chronic inflammation, infection, lichen planus, psoriasis, or eczema.
Additionally, there have been theories suggesting that the condition could be due to a persistent infection with a bacterium called Mycobacterium smegmatis or the human papillomavirus (HPV). However, it’s important to note that these theories haven’t been proven as of yet.
Risk Factors and Frequency for Balanitis Circumscripta Plasmacellularis
Balanitis circumscripta plasmacellularis is a condition that is often not reported or diagnosed adequately, though it occurs with some frequency. Two reports found that this condition was present in around 10% of their patient samples suffering from related ailments. It’s particularly common among uncircumcised men of older age groups. Unlike other similar skin conditions affecting the penis, this disease is usually not considered to be a precursor to cancerous growths.
- Balanitis circumscripta plasmacellularis is commonly underreported and underdiagnosed.
- One report found it in 27 out of 357 patients with genital disease, another found it in 26 out of 226 penile biopsies.
- It is more often seen in older, uncircumcised men.
- Unlike other similar conditions, it is usually not a precursor to cancer.
Signs and Symptoms of Balanitis Circumscripta Plasmacellularis
Balanitis circumscripta plasmacellularis is a condition that often appears as perfectly symmetrical, marked, red, shiny patches with many tiny red dots known as “cayenne pepper spots.” These spots typically show up on the glans (head of the penis), the prepuce (foreskin), or both. There are also cases where it shows up as vegetation-like, corroded, or multiple lesions.
Most of the time, this condition doesn’t cause any symptoms, although it might lead to itching or a burning sensation. It is mostly seen in older men who are not circumcised. Unfortunately, this issue tends to stick around for a long time – from months to years – and doesn’t usually respond well to typical creams or lotions used for treatment.
Testing for Balanitis Circumscripta Plasmacellularis
When a person first notices the skin condition, the lesions have often been there for over three months already. They are glossy and red. Standard treatments applied on the skin usually do not improve these lesions, except in certain cases. It’s important to note that there should be no signs of an infection.
A helpful hint for diagnosing balanitis circumscripta plasmacellularis might be how well the skin reacts to an ointment called mupirocin 2%. However, this isn’t a sure-fire way to confirm the condition, as the reliability of this clue hasn’t been definitively proven.
In recent times, a skin imaging technique called dermoscopy has been used to study this condition in 11 patients. Some intriguing observations include curved blood vessels in different shapes, areas of orange-brownish color without any particular structure, irregular blurred blood vessels, and small dotted blood vessels. These findings could help doctors tell balanitis circumscripta plasmacellularis apart from other similar skin conditions like Erythroplasia of Queyrat, psoriasis, and nonspecific balanoposthitis.
Another highly specialized imaging tool, reflectance confocal microscopy, enables experts to distinguish between balanitis and skin cancer in its early stage. Balanitis appears to show a pattern similar to a honeycomb full of cells, and worm-like blood vessels. In contrast, early-stage skin cancer shows round cells within an abnormal honeycomb pattern.
Even with these techniques, a doctor might not always be able to confirm balanitis circumscripta plasmacellularis just by examining the patient. In some situations, a skin biopsy might be needed to provide a definitive diagnosis.
Treatment Options for Balanitis Circumscripta Plasmacellularis
Circumcision is typically the first course of treatment for this condition and is known to bring about long-term relief. However, due to the sensitivity of the area, many patients are hesitant to go for this option. Other available treatments include applying steroid creams or ointments, light therapy, or undergoing laser treatment. However, the disease tends to reappear with these alternative treatments.
Carbon dioxide and erbium:yttrium-aluminum-garnet (Er:YAG) lasers are successful ways to treat the condition. The carbon dioxide laser head spins fast, spending less time on a specific area, reducing the chances of damage. Another study using Er:YAG lasers on 20 people showed that most people had a completely healed skin within 10 days. Follow-ups showed that the condition had cleared completely from 3 to 30 months. This form of treatment demonstrates precision, minimal risk of scarring, and quick healing time.
Although light therapy shows promise, there hasn’t been enough research for it to be confirmed as a regular treatment. It is, however, known to be a safe form of having the condition removed and has been used in persistent cases.
An ointment called Mupirocin 2% was used in a few instances, and positive results were seen after being applied three times daily for 6-12 weeks. The success of this treatment suggests the condition may be linked to bacterial colonization, but further studies need to be done for confirmation.
Other treatment options using creams like tacrolimus and pimecrolimus have resulted in a complete cure after 3 to 8 weeks of therapy. However, there are concerns regarding a possible connection between these creams and cancer, so a biopsy must be taken to rule out cancer before starting this treatment.
Although steroid cream therapy has been suggested, there isn’t enough evidence to confirm its effectiveness. In one case, patients saw quick improvement after applying a preparation of oxytetracycline, nystatin, and clobetasone butyrate. Still, further research is needed to confirm its effectiveness.
Imiquimod 5% cream has been used with positive results in a few cases. The cream is believed to boost the body’s immune response. However, the best dosage, duration, and long-term effectiveness need to be studied more.
Treatments like radiation therapy, cryotherapy, superficial skin scraping, topical antifungal creams, and the drug griseofulvin have all proven to be ineffective.
What else can Balanitis Circumscripta Plasmacellularis be?
When diagnosing a patient, a doctor may look into several other conditions that have similar symptoms before reaching a final diagnosis. During this, they might consider:
- Candidiasis (a fungal infection)
- Contact dermatitis (skin inflammation caused by contact with certain substances)
- Fixed drug eruption (a skin reaction to a certain medication)
- Kaposi sarcoma (a type of cancer that forms in the lining of blood and lymph vessels)
- Herpes simplex virus (an infection that causes herpes)
- Lichen planus (a skin rash triggered by the immune system)
- Lichen sclerosus (a rare skin condition that usually affects the genital area)
- Pemphigus vulgaris (a serious skin disorder)
- Erythroplasia of Queyrat (a type of skin cancer that affects the penis)
- Psoriasis (a skin disease that causes red itchy plaques)
- Reiter disease or reactive arthritis (a type of arthritis caused by an infection)
- Secondary syphilis (the second stage of a bacterial infection)
- Squamous cell carcinoma (a type of skin cancer).
It’s also possible for a patient to have a co-infection with Candida (a type of fungus). You should keep in mind that this is a simplified explanation, and the doctor would need to consider many factors before concluding.
What to expect with Balanitis Circumscripta Plasmacellularis
Balanitis circumscripta plasmacellularis is typically believed to be a harmless condition. However, there have been a few cases where it was linked with a type of skin cancer called squamous cell carcinoma. For instance, in 1999, a patient with this condition was found to have penile carcinoma, as detailed by a doctor named Joshi.
In 2001, another doctor named Bunker suggested that some instances of conditions such as lichen sclerosus, lichen planus, Bowenoid papulosis, and penile cancer showed signs of changes that are typically associated with Zoon balanitis. This led to the suggestion that Zoon balanitis might potentially be a condition that can develop into cancer. However, more research is needed to confirm this link.
Possible Complications When Diagnosed with Balanitis Circumscripta Plasmacellularis
Balanitis circumscripta plasmacellularis is a condition that can cause localized issues like discomfort, painful urination, or itchiness. With time, the affected area might enlarge or spread. One main worry related to this condition is the potential risk of developing penile cancer if misdiagnosed. Therefore, it’s recommended to receive follow-up care for at least five years after treatment, particularly if the diagnosis wasn’t confirmed with a biopsy.
Preventing Balanitis Circumscripta Plasmacellularis
Doctors have an essential job in teaching patients how to take care of their hygiene properly. This includes teaching men who haven’t had a circumcision how to keep their genital areas clean by frequently washing the head and the skin covering it. Furthermore, patients should know how vital it is to quickly let their doctor or healthcare provider know if they notice any unusual marks or changes in the color of the genital areas.
