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
