Zoon Balanitis Revisited: Report of Balanitis Circumscripta Plasmacellularis Resolving With Topical Mupirocin Ointment Monotherapy

March 2017 | Volume 16 | Issue 3 | Case Report | 285 | Copyright © 2017

Michael A. Lee MDa and Philip R. Cohen MDb

aMedical College of Wisconsin, Milwaukee, WI bUniversity of California San Diego, San Diego, CA

Abstract

INTRODUCTION: Zoon balanitis is an idiopathic benign inflammatory condition of the glans penis and prepuce. A patient with biopsy confirmed diagnosis of Zoon balanitis who was successfully treated with topical mupirocin ointment monotherapy is described.

METHOD: A search using PubMed database was performed using the following terms: Zoon balanitis (cases, diagnosis, treatment of), balanitis circumscripta plasmacellularis, and mupirocin. Relevant papers and their reference citations were reviewed and evaluated.

RESULTS: The gold standard of treatment for Zoon balanitis has previously been circumcision. More recently, topical calcineurin inhibitors have been shown to be effective. Our patient had successful resolution of his Zoon balanitis after 3 months of mupirocin ointment monotherapy.

DISCUSSION: Zoon balanitis is a benign inflammatory dermatosis. Previous successful treatment modalities include circumcision, phototherapy, laser therapy, and topical calcineurin inhibitors. Topical mupirocin ointment twice daily resulted in resolution of Zoon balanitis in our patient. Additional evaluation of mupirocin ointment as a therapeutic agent should be considered as a potential first-line therapy in patients with Zoon balanitis.

J Drugs Dermatol. 2017;16(3):285-287.

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Zoon balanitis, also referred to as balanitis circumscripta plasmacellularis, is a rare, idiopathic, benign inflammatory condition of the penis that mainly affects middle-aged to elderly uncircumcised men. The standard of treatment is circumcision, but many patients prefer a non-surgical modality. We report a man with Zoon balanitis who was successfully treated with topical mupirocin ointment.

CASE REPORT

A 62-year-old healthy, heterosexual, uncircumcised male presented for our evaluation of an asymptomatic red lesion on his foreskin and glans penis that he noticed after beginning ciprofloxacin for prostatitis. His primary care physician initially prescribed lotrimin, which improved the rash on his glans penis; however, the lesion on his foreskin persisted. In addition, he had phimosis and experienced difficulty retracting his foreskin during intercourse.Clinical examination revealed an uncircumcised man. Upon retraction of the foreskin, a 1cm erythematous, non-tender plaque extending from the distal penile shaft to the proximal glans penis and involving the corona was visualized (Figure 1a and b). Several conditions were considered in the clinical differential diagnosis at the time: candidiasis, condyloma, dermatitis, erythroplasia of Querat, lichen planus, or Zoon’s balanitis.A biopsy was performed to obtain tissue for microscopic examination. There was a lymphoplasmacytic band-like infiltrate along the dermal-epidermal junction. A periodic-acid Schiff stain failed to identify fungal organisms. Laboratory investigation, including a rapid plasma regain and HIV assay, was negative. Correlation of the patient’s history, clinical morphology, pathologic features, and laboratory studies established a diagnosis of balanitis circumscripta plasmacellularis.The patient had been given mupirocin ointment to apply to the biopsy site three times daily. Treatment options were subsequently discussed with the patient. These included circumcision and topical tacrolimus 0.1% ointment. The patient took several weeks to reach a decision. At his initial follow-up, the lesion had begun to diminish in size. Based on this observation, he elected to continue using mupirocin ointment twice daily with bimonthly follow-up. Complete resolution was noted after three months of therapy (Figure 2a and b). He remained in clinical remission without recurrence two months after mupirocin was discontinued.

DISCUSSION

Since its initial description by Zoon in 1952, balanitis circumscripta plasmacellularis has been a rare benign disease included in the differential of a persistent penile lesion. It mainly affects

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