Balanitis Circumscripta Plasmacellularis - Types, Diagnosis, Treatment, and Complications

What Are Plasma Cells?

Plasma cells are a type of white blood cell present in the body. They are formed in the bone marrow from the B-lymphocytes. Bone marrow is a soft tissue present at the center of hollow bones. Plasma cells form antibodies and are responsible for humoral immunity. These cells protect the body from bacterial infections. If the plasma cells are absent, the patient becomes vulnerable to infections. The immature form of a plasma cell is known as a plasmablast, which secretes many antibodies. In other words, plasma cells can be termed antibody factories because they release antibodies when stimulated by an antigen.

What Is Balanitis Circumscripta Plasmacellularis?

Balanitis circumscripta plasmacellularis is also known as plasma cells balanitis or Zoon balanitis, named after its discoverer JJ Zoon. It is a chronic, rare, non-cancerous, and idiopathic disease that affects the foreskin of the penis. This condition is commonly seen in uncircumcised males (uncircumcised males are those whose foreskin was removed at an early age). The penis mainly consists of a foreskin, head (glans), and tip. Balanitis circumscripta plasmacellularis is mainly characterized by multiple pinpoint red spots on the foreskin. Though the condition is benign (non-cancerous), it can turn malignant (cancerous) and is frequently associated with squamous cell carcinoma. Sometimes, the condition is present for a prolonged period, but the patient is unaware of it. As a result, the condition worsens, and the patient requires medical care and attention.

What Are the Different Types of Balanitis?

Balanitis is characterized by the pain and inflammation of the penile head. The different types of balanitis are described in the table below:

What Are the Causes of Balanitis Circumscripta Plasmacellularis?

The exact cause of balanitis circumscripta plasmacellularis is still unknown. However, scientists believe that the following factors increase the risk of balanitis:

• The retention of urine in the foreskin provides a moist environment for bacterial growth. As a result, itching and inflammation of the penis head are commonly seen, resulting in balanitis.

• Poor genital hygiene.

• Obesity.

• Trauma or penile injury.

• Men suffering from sexually transmitted diseases are at a higher risk of developing balanitis circumscripta plasmacellularis.

• Studies have also suggested that chronic infection with human papillomavirus and Mycobacterium smegmatis stimulate an immediate hypersensitivity response. This causes irritation and inflammation of the penis.

• Dysfunctional foreskin due to lichen sclerosus and psoriasis is one of the reasons for balanitis circumscripta plasmacellularis.

What Are Some of the Signs and Symptoms of Balanitis Circumscripta Plasmacellularis?

The patient might remain asymptomatic in the initial stages of balanitis. However, the following symptoms are seen later on:

• Pruritis or itching.

• Burning sensation.

• Dysuria (painful urination).

• Decrease in the normal sensation of the penis.

• Painful erection.

• Difficulty in starting the urine stream.

• Presence of bloodstains on the undergarments.

• Multiple pinpoint erythematous (red) patches on the penis head and the foreskin.

What Methods Are Used to Diagnose Balanitis Circumscripta Plasmacellularis?

Balanitis circumscripta plasmacellularis is mainly seen in people who did not undergo circumcision. No specific tests are recommended because the condition becomes visible on physical examination. The diagnostic methods have been described below -

1. Medical History: The medical history provides an idea about the symptoms of the condition, the time of their onset and progression, the drug history, and the family history. For example, patients suffering from sexually transmitted diseases, urinary tract problems, and skin diseases are more likely to develop balanitis circumscripta plasmacellularis.

2. Physical Examination: The doctor examines the penis to look for signs of inflammation. Initially, multiple shiny red to orange-colored patches are seen on the penis head. These patches appear yellow with pinpoint “cayenne pepper” spotting as the disease progresses. Sometimes, the patient might notice blood spots on his undergarments.

3. Biopsy: Biopsy is a procedure in which a tissue sample is taken from the penis to check the size and shape of the cells. It distinguishes balanitis circumscripta plasmacellularis from carcinoma in situ (a type of skin cancer).

4. Confocal Microscopy: It is an optical imaging technique that helps produce three-dimensional (3D) images of a structure. The tissue sample obtained after the biopsy is examined under a confluent microscope to look at the size and shape of the cells. The cells show a typical honeycomb pattern in balanitis circumscripta plasmacellularis.

5. Dermoscopy: It is a procedure done to evaluate the skin surface. During this procedure, the skin is covered with liquid, mainly oil or alcohol, and examined under a microscope-like device known as a dermatoscope. It helps to check the abnormalities present on the skin surface.

How to Manage Balanitis Circumscripta Plasmacellularis?

The treatment depends upon the severity of the condition. Mild cases can be treated by conservative methods, whereas severe cases require surgical intervention. The treatment options have been described below:

1) Surgery - Surgical treatment is only indicated for patients suffering from phimosis or conservative treatments that have failed to manage the condition. The foreskin is removed surgically because it provides an environment for bacterial growth. However, circumcision is only useful when the condition is restricted to the penis. Some patients refrain from circumcision, but it is the first-line therapy to manage balanitis plasmacellularis circumscripta.

2) Topical Steroids -Topical steroids effectively treat mild cases of balanitis circumscripta plasmacellularis. Scarring and phimosis are commonly seen if the disease progresses to a severe stage and the steroids are ineffective. A combination cream of Nystatin, Clobetasone Butyrate, and Oxytetracycline is commonly used and has shown good results.

3) Other Medications - The following medications have helped in dealing with balanitis circumscripta plasmacellularis:

• Topical calcineurin inhibitors (Tacrolimus and Pimecrolimus).
• Topical Imiquimod.
• Topical Mupirocin.
• Fusidic acid cream.

4) Laser Treatment - Treatment with Erbium-doped yttrium aluminum garnet (Erbium YAG) laser has shown wonderful results. Re-epithelization and complete clearing of the skin lesions was achieved in ten days.

What Are the Complications of Balanitis Circumscripta Plasmacellularis?

Usually, the patient does not present with any complications as the infection subsides after applying topical steroids. However, the following complications occur if the condition is diagnosed late:

1. Paraphimosis - Normally, boys can pull back their foreskin to cover the tip of the penis by around ten years of age. However, the problem arises when the person cannot pull the foreskin back to its normal position. As a result, the foreskin gets stuck behind the head of the penis and becomes swollen. The blood supply to the tip of the penis is lost, resulting in a condition known as paraphimosis.

2. Painful Erection - The penis contains spongy tissues that receive blood and increase in size. When the person is sexually stimulated, the brain commands the arteries to open completely. As a result, the blood flows rapidly into the spongy tissues, and the penis gets enlarged. When this blood gets trapped in the penis, the condition is known as priapism or painful erection.

How to Maintain Penile Hygiene?

The following help to maintain penile hygiene:

• Do not use scented soaps or lotions to clean the penis.

• Always clean the penis tip and head after urinating.

• Wash the penis with warm water to prevent bacterial infection.

• Use a soap-free cleanser to clean the penis.

• After cleaning the area, dry it with a towel because moisture facilitates bacterial growth.

• Make sure to wash the genitals after intercourse.

Conclusion:

Balanitis circumscripta plasmacellularis, or Zoon’s balanitis, is a condition in which the penis head becomes inflamed. Uncircumcised males are at a higher risk of developing this condition because their foreskin provides shelter to the bacteria. This condition was previously considered rare, but it is now commonly seen in adults and children. Multiple pinpoint red nodules on the penis head are characteristic of this disease. The treatment depends upon how early the condition is diagnosed. Topical steroids are helpful in mild to moderate cases, whereas surgical intervention is required in severe cases. Laser treatment has proved beneficial against skin diseases. However, the effectiveness of laser treatment is still under research. So, the patient must consult the doctor immediately to learn more about the condition and the treatment.