Genitourin Med 1995;71:32-34

Plasma cell balanitis: clinical andhistopathological features response tocircumcision

B Kumar, R Sharma, M Rajagopalan, B D Radotra

Departments ofDermatology,Venereology andLeprology andPathology,Postgraduate InstituteofMedical Educationand Research,Chandigarh-160012,IndiaB KumarR SharmaM RajagopalanB D RadotraCorrespondence to:Dr Bhushan Kumar,Additional Professor,Department ofDermatology, Venereologyand Leprology, PGIMER,Chandigarh-160012, India.Accepted for publication2 September 1994

AbstractObjective-To evaluate the clinico-pathological features and response tocircumcision in patients with plasma cellbalanitis.Subjects and method-32 uncircumcisedmen with penile lesions typical of plasmacell balanitis. Twenty specimens were

available for histopathology.Results-Lesions involved prepuce andglans in 17, prepuce only in 10 and in 5were localised to glans alone or extendedto coronal sulcus. Histopathology showedvariable features but were consistent withthe diagnosis of plasma cell balanitis.Haemosiderin pigment could be detectedin only three specimens of patients withshorter duration of the disease. Twentyseven patients were treated with circum-cision and no recurrence was noticed in3 years of follow up.

Conclusion-Circumcision is an effectivetreatment modality in plasma cell balani-tis. Absence of haemosiderin pigment inmajority of tissue sections is difficult toexplain but may be related to longerduration of the disease.

(Genitourin Med 1995;71:32-34)

Keywords: Balanitis, Plasma cell, Circumcision

IntroductionSince the original description of a distinctivebalanitis by Zoon which he termed bal-anoposthitis chronica circumscripta plasma-cellularis in 1952,1 there have been fewreports of this condition in the literature.Subsequently similar lesions have beendescribed on the vulva23 and the lips.4 Thisrare disorder consists of a single, red, shinyand smooth patch involving the glans penis or

adjacent prepuce or both.' 5-7 The characteris-tic histological features are: a band-like mainlyplasmacytic inflammatory infiltrate of theupper dermis, dilated capillaries and depositsof haemosiderin.' 5Treatment with topicalsteroids8 is palliative at best, with manypatients being totally unresponsive.679Circumcision which was advocated as the bestmodality of treatment many decades ago hasbeen reported to be beneficial in the recentreports6 7 10 We report 32 cases with this condi-tion 27 of whom were treated successfullywith circumcision.

Patients and methodsThirty two uncircumcised men presented witha shiny, reddish, macular or minimally infil-trated lesion(s), on the glans penis or prepuceor both. Clinical details are shown in thetable. All of them had received topical treat-

Clinical details ofpatientsAge Duration

No. (years) (years) Symptom(s) Site of lesion Circumcisions1 40 1 Asymptomatic Glans and prepuce Done2 38 3 Asymptomatic Glans and prepuce Done3 28 4 Asymptomatic Prepuce Not done4 37 1 Pruritis Prepuce Done5 24 1 i Asymptomatic Prepuce and glans Not done6 70 4 Pruritis Prepuce Done7 55 2 Pruritis Prepuce Done8 38 4 Asymptomatic Prepuce Done9 56 2 Asymptomatic Prepuce and glans Done10 70 3 Asymptomatic Prepuce and glans Done11 55 3 Asymptomatic Prepuce and glans Done12 48 2 Asymptomatic Prepuce and glans Done13 65 10 Asymptomatic Prepuce and glans Done14 64 25 Asymptomatic Prepuce and glans Done15 30 2 Asymptomatic Prepuce and glans Done16 45 1 Pruritis Prepuce Done17 54 4 Asymptomatic Prepuce Not done18 50 3 Asymptomatic Prepuce and glans Done19 40 3 Asymptomatic Prepuce and glans Done20 42 3 Increased sub-prepucial discharge Glans with extension to coronal sulcus Done21 47 3 Asymptomatic Prepuce and glans Done22 50 5 Asymptomatic Glans Not done23 63 1 Mucopurulent sub-prepucial discharge Prepuce and glans Done24 40 1 Increased sub-prepucial discharge Prepuce Done25 42 3/12 Increased sub-prepucial discharge Glans, prepuce coronal sulcus Done26 56 3 Asymptomatic Glans and prepuce Done27 28 1 Asymptomatic Prepuce and coronal sulcus Not done28 70 3 Asymptomatic Glans Done29 42 1 Asymptomatic Glans Done30 44 6/12 Asymptomatic Prepuce Done31 37 1 Asymptomatic Glans Done32 24 11 Increased sub-prepucial discharge Glans and prepuce Done

*Lesions in all patients healed after circumcision after variable periods of time.

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Plasma cell balanitis: clinical and histopathologicalfeatures-response to circumcision

Figure 1 Attenuatedepidermis containinglozenge shapedkeratinocytes with densedermal infiltrate rich inplasma cells(H&E x 140).

ment with steroids, antifungal agents andcombinations of steroids with antifungals or

antibacterials. Some of them responded par-tially, but temporarily. Biopsy material or cir-cumcised tissue was available from 20patients. In addition to routine staining withhaematoxylin and eosin, Pearl's stain wasused to detect haemosiderin. Histological fea-tures observed were variable but attenuatedthickness of epidermis, dense dermal infiltratecomposed predominantly of plasma cells andscattered lymphocytes were typical, (fig. 1 and2). Haemosiderin deposits were present inonly three specimens.

All except five patients underwent circum-cision and the lesions resolved within a fewmonths. No recurrences were noticed in any

Figure 2 Photomicrograph showing plasma cell infiltrate, dilated capillaries andextravasated RBCs in upper dermis (H& E x 280).

of the circumcised men followed for up to 3years.

DiscussionPlasma cell balanitis can often be confusedclinically with other conditions, such as ery-throplasia of Queyrat, fixed drug eruption,psoriasis, lichen planus, secondary syphilis,candidiasis and Reiter's disease.7 The classicalfeature of plasma cell balanitis is the appear-ance of a shiny, glazed, reddish macularerythematous lesion with multiple pin-pointbright red spots (cayenne-pepper spots) onthe glans penis or prepuce or both in middleaged or elderly men.1579 In some instances,erosions with a tendency to bleed are present.Lesions with fleshy buds and erosions andrarely vegetating forms have been described."All our patients had the classical characteristicappearance. Their age varied widely from 24to 70 years. The aetiology of plasma cellbalanitis is unknown. Chronic infection byMycobacterium smegmatis, heat, constant fric-tion and poor hygiene are believed to be thecausative factors.7 12 The clearance of lesionsafter circumcision and occurrence of diseasealmost exclusively in the uncircumcised men5lend support to theories regarding role of con-stant friction and probably poor hygiene in itscausation. 12 The primary event in patho-genesis seems to be extravasation of bloodand subsequent haemosiderin deposition.Recently Leonforte"3 had described the pres-ence of phagocytosed material in the plasmacells (in addition to its presence inmacrophages and endothelial cells) which heproposed could be iron. The absence ofhornyand granular layers, occasional dyskeratoticcells but without atypia and even predomi-nant lymphocytic infiltrate have beendescribed.2 Immunological studies have sug-gested IgG, and IgA producing plasma cells.'2Most of our patients showed the uniformlycharacteristic histological changes, namely,epidermal thinning, loss of rete ridges,"lozenge keratinocytes" and "watery spongio-sis", proposed as unique features of plasmacell balanitis by Souteyrand et al.5 There was asubepidermal, predominantly plasmacyticinflammatory infiltrate with proliferation andvertical orientation of dermal vasculature anderythrocyte extravasation in all our cases,as described by others. 1 5 7 However,haemosiderin deposition was present in onlythree of our cases, which has been earlierdescribed as one of the characteristic histolog-ical features.' ' Absence of haemosiderin inmost of the sections is difficult to explain but itmay be due to the longer duration of the dis-ease. The positive specimens were frompatients with recent lesions. In a recent reportthe presence of excessive haemosiderin deposi-tion has been suggested to be a feature of alichen-aureus like variant of plasma cell bal-anitis. 14

Patients demand treatment because of dis-comfort and the presence of a disfiguring dis-ease on a vital sex organ. Most patients withthe malady are not willing to tolerate an

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Kumar, Sharma, Rajagopalan, Radotra

annoying, embarrassing lesion to which theyhave to apply creams and ointments for longperiods with very little response.67Circumcision was first recommended as acure in 1956.15 Subsequently this relativelysimple but not very popular procedure hasbeen used satisfactorily and the response wasreported to be even dramatic.6 710 All ourpatients treated by circumcision showed com-plete resolution of even the lesions on theglans in a few months. We recommend arevival of this simple procedure for the treat-ment of Zoon's balanitis.

1 Zoon JI. Balanoposthite chronique circonscrite benigne aplasmacytes. Dermatologica 1952;105: 1-7.

2 Jonquieres EDL, DeLutzky FK. Balanitis et vulvites pseu-doerythroplasiques chroniques. Ann Dermatol Venereol1980;107:173-80.

3 Woodruff JD, Sussman J, Shakfeh S. Vulvitis circum-scripta plasma cellularis. A report of four cases. JReproduc Med 1989;34:369-72.

4 Baughman RD, Berger P, Pringle WM. Plasma cell cheili-tis. Arch Dermatol 1974;11O:725-6.

5 Souteyrand P, Wong E, MacDonald DM. Zoons balanitis(balanitis circumscripta plasmacellularis). Br J Dermatol

1981;105:195-9.6 Sonnex TS, Dawber RPR, Ryan TJ, Ralfs IG. Zoon's

(plasma-cell) balanitis: treatment by circumcision. Br3JDermatol 1982;106:585-8.

7 Murray WJG, Fletcher MS, Yates-Bell AJ, Pryor A, DarbyAJ, Packham OA. Plasma cell balanitis of Zoon. Br J

Urol 1986;58:689-91.8 Suurmond MD. S Maddin, ed. In: Current Dermatologic

Managements 2nd edition, St Louis, CV MosbyCompany, 1975:81.

9 Ive FA. Diseases of the umbilical, perianal and genitalregions. In: Champion RRH, Burton JL, Ebling FJGeds. Textbook of Dermatology 5th ed. Oxford. BlackwellScientific Publications, 1992:2812-3.

10 Ferrandiz C, Ribera M. Zoon's balanitis treated by cir-cumcision. Journal of Dermatologic Surgery and Oncology1984;10:622-5.

11 Dupre A, Bonafe JL, Lassere J, et al. Lesions bourgeon-nantes preputiales a plasmocytes: Variante anatomo-clinique de la balanoposthite chronique circonscritebenigne de Zoon. Bull Soc Fr Dermatol Syphiligr1976;83:63-8.

12 Toonstra J, Vanwichen DF. Immunohistochemical charac-terization of plasma cells in Zoon's balanoposthitis and(pre) malignant skin lesions. Dermatologica1986;172:77-81.

13 Leonforte JF. Balanitis circumscripta plasmacellularis:Case report with ultrastructural study. Acta DermatolVenereal (Stockh) 1982;62:352-6.

14 Kossard S, Shumaek S. Lichen aureus of the glans penis asan expression of Zoon's balanitis. JfAm Acad Dermatol.1989;21:804-6.

15 Sutton RL. Diseases of the Skin 11th ed. St. Louis, CVMosby Company 1956:894.

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