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

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


Michael A. Lee MDa and Philip R. Cohen MDb

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

Several treatment options, of ranging success, are available for patients with Zoon balanitis. Observation without therapy rarely results in self-resolution of the lesion. Therefore, most patients elect for treatment due to anxiety and/or cosmetic disfigurement or because of symptoms. Circumcision is considered the gold standard for definitive treatment, and has been shown to protect against common infective and neoplastic penile dermatoses.4,6 Recent studies have shown good efficacy using photodynamic therapy, or carbon dioxide laser or erbium:YAG laser.9-11 However, despite their proven effectiveness, most patients reject these therapeutic options due to the location of the lesion. Nonsurgical approaches for the treatment of Zoon balanitis have also been attempted. Originally, these consisted of topical corticosteroids with or without adjuvant topical antibiotics and/or topical antifungals, however reports of satisfactory treatment with these topical agents were rare.12,13 Topical calcineurin inhibitors, known to be effective in controlling diverse inflammatory mucous membrane and genital diseases, were initially documented as a possible treatment option in 2004.14 Subsequently, multiple studies using tacrolimus and pimecrolimus have demonstrated good efficacy of treatment with few side effects.15-16 Hence, topical calcineurin inhibitors have become more widely accepted as an initial medical therapy for Zoon balanitis.Mupirocin is an antibiotic isolated from Pseudomonas fluorescens.17 It acts by reversibly binding to the enzyme isoleucyl t-RNA synthetase, and thereby inhibits protein synthesis.18 Mupirocin is commonly used in the treatment of bacterial skin infections such as impetigo, as well as methicillin-resistant staphylococcus aureus (MRSA) infections. To our knowledge, the reported patient represents the first successful treatment of Zoon balanitis with mupirocin monotherapy. Our findings are limited to a single patient. His complete response to mupirocin monotherapy could suggest that, in some patients with Zoon balanitis, there may be a bacterial component involved in the pathogenesis of the disease. The excellent safety profile of mupirocin also might prompt clinicians to consider this as a first-line topical therapy in patients with newly diagnosed Zoon balanitis.

CONCLUSION

Zoon balanitis is a benign inflammatory condition of the penis with an unknown pathogenesis. Current treatment options primarily include either circumcision, or topical calcineurin inhibitors. We report a man with biopsy confirmed balanitis circumscripta plasmacellularis that was successfully treated with mupirocin monotherapy, a treatment modality that has not been previously evaluated. Our findings not only prompt us to recommend future investigations regarding the efficacy of mupirocin monotherapy in a larger number of Zoon balanitis patients, but also to speculate that in some individuals a bacterial etiology may contribute to the pathogenesis of balanitis circumscripta plasmacellularis

DISCLOSURES

The authors have nothing to disclose, including any affiliation with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript (eg, employment, consultancies, stock ownership, honoraria, expert testimony).

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AUTHOR CORRESPONDENCE

Philip R. Cohen MD mitehead@gmail.com