Resident Rounds Part III. Case Report: Genital Ulcers

October 2014 | Volume 13 | Issue 10 | Features | 1290 | Copyright © October 2014

Jeremy M. Hugh MD, Kendra Lesiak MD, Laura A. Greene MD, and Joseph C. Pierson MD

University of Vermont College of Medicine, Burlington, VT

Abstract
Zoon’s balanitis, is typically found in older, uncircumcised males and can be asymptomatic, pruritic, or cause dysuria. The typical appearance is erythematous, discrete, moist plaques with a “cayenne pepper” speckled appearance and an orange hue on the glans penis and sometimes prepuce, which may display “kissing lesions” on areas that are in direct contact with the lesions. These may eventually erode and leave a “rusty stain”. Histologically, these have a dense lichenoid infiltrate in the upper and mid dermis with abundant plasma cells.

CASE REPORT

A 62-year-old Asian male with a history of rheumatoid arthritis presented to the clinic complaining of a red penile rash. It had been present for approximately 8 years and waxed in waned in terms of redness and area involved, but slowly enlarged to cover more area. He denied any symptoms associated with the rash including pain or tenderness, discharge, or bleeding. Previous treatments included an unknown topical steroid ointment, which only helped for a few months. He denied a history of any new medications in relation to this rash and had no new sexual contacts or high-risk behaviors.
On exam, on the glans of an uncircumcised penis there was a diffuse, deep red, and erythematous patch. On the distal shaft of the penis was a similar appearing patch sparing the coronal sulcus with a “cayenne pepper” red/orange, speckled periphery. A deep shave biopsy showed a superficially attenuated mucosal surface with a dense inflammatory infiltrate in the dermis composed predominantly of plasma cells mixed with lymphomononuclear cells. Microorganism stains were negative.

DISCUSSION

Zoon’s balanitis is typically found in older, uncircumcised males and can be asymptomatic, pruritic, or cause dysuria. The typical appearance are erythematous, discrete, moist plaques with a “cayenne pepper” speckled appearance and an orange hue on the glans penis, and sometimes prepuce, which may display “kissing lesions” on areas that is in direct contact with the lesions. These may eventually erode and leave a “rusty stain”.1 Histologically, these have a dense lichenoid infiltrate in the upper and mid dermis with abundant plasma cells.
The traditional teaching of Zoon’s balanitis is that it is generally a benign, chronic, inflammatory process in uncircumcised males, which is best treated by circumcision. There is a case report of this condition occurring in a circumcised male2 and there are many reports of it being treated medically rather than surgically. Zoon’s balanitis is reported to have been treated successfully
table 1