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Balanitis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Balanitis is a general term for inflammation of the glans penis, which may also extend to the foreskin (prepuce), in which case it is called balanoposthitis. It may be seen in all age groups and occurs more frequently in the uncircumcised. Etiologies include inflammatory, infectious, and neoplastic disorders. All types of balanitis may be aggravated by poor hygiene, warmth, and friction. This chapter will focus on Zoon balanitis and balanitis xerotica obliterans (BXO, lichen sclerosus).
Balanitis plasmacellularis (Zoon balanitis) represents a non-venereal, non-specific, chronic inflammation of the glans penis occasionally extending to the foreskin. It normally occurs in uncircumcised men past the second decade of life, but has been reported in children. The shiny, red, sharply demarcated patch is often asymptomatic, though symptoms of pruritus, dysuria, and pain may be reported. The evaluation for Zoon balanitis should include a thorough history and clinical workup to exclude genital herpes, secondary syphilis, and other etiologies of penile lesions. Zoon balanitis can also be associated with dermatoses of the genital area such as erosive lichen planus, lichen sclerosus, and penile psoriasis as a type of reaction pattern.
Other differential diagnoses (allergic contact dermatitis, erythroplasia of Queyrat or Bowen disease of the glans penis, and pemphigus vulgaris) should be ruled out. Biopsy demonstrates an atrophic epidermis with diamond-shaped keratinocytes overlying a predominately plasma cell–rich, bandlike infiltrate in the papillary dermis. Complications may include fissuring and pain, phimosis (inability to retract the foreskin due to agglutination/scarring), and stenosis of the urethral meatus; surgical correction of sequelae may be necessary.
Lichen sclerosus (BXO) is treated similarly to Zoon (plasma cell) balanitis. Lichen sclerosus is also of unclear etiology, although an autoimmune pathogenesis associated with other autoimmune conditions may be involved. This condition may be underrecognized in boys. It is important to identify the disorder and have continued follow-up because of the approximately 5% lifetime risk of developing a squamous cell carcinoma.
Management Strategy
Evaluation of a patient with balanitis should include a chief complaint, history of present illness, past medical and surgical history, medications, allergies, and review of systems. Specific information should be sought regarding sexual habits and alleviating or exacerbating factors. To identify potential allergens and/or irritants, the patient’s genital hygiene practices and the use of oral and topical agents (condoms, spermicides, sexual-enhancing products, lubricants, etc.) should be sought. A complete mucocutaneous examination, including extragenital sites, should be performed. The genital examination includes skin and soft tissue structures extending from the lower abdomen to the perianal skin/gluteal cleft. Examination findings should direct the acquisition of microbiologic studies (KOH preparation; bacterial, fungal, and viral cultures), biopsy (hematoxylin and eosin, direct immunofluorescence), and serologic studies. All males with balanoposthitis should be screened for diabetes.
Patients with balanitis should be instructed about appropriate local hygiene, including retraction of the foreskin before cleansing. The glans and shaft should be cleaned with plain water or normal saline twice daily and after sexual activity. Soap and topical products may be irritants or allergens and should be avoided. A bland emollient applied twice daily will minimize friction and improve barrier function.
Medical therapy for balanitis is directed by etiology. Circumcision is indicated in refractory cases. Surgical procedures may be required for patients with significant anatomic distortion or compromised urinary function. Collaboration with urologic specialists is essential.
Specific Investigations
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KOH microscopy for fungi
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Tzanck smear or direct fluorescent antigen testing for herpes viruses
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Swab culture for bacteria, viruses, and fungi
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Biopsy for routine histopathology and direct immunofluorescence, if indicated
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Hemoglobin A1c
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Urinalysis and urine glucose
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Serologic tests for syphilis, herpes virus, and human immunodeficiency virus
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Serologic tests for vesiculobullous diseases (systemic lupus erythematosus, pemphigus vulgaris, bullous pemphigoid, etc.)
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Patch testing
2013 European guideline for the management of balanoposthitis
Edwards S, Bunker C, Ziller F, et al. Int J STD AIDS 2014; 25: 615–26.
Comprehensive review of the many causes of balanitis with specific recommendations for evaluation and management.
Zoon balanitis: a comprehensive review
Dayal S, Sahu P. Indian J Sex Transm Dis 2016; 37: 129–38.
A complete review of Zoon balanitis with history, differential diagnosis, and treatment.
Balanitis xerotica obliterans: an update for clinicians
Nguyen ATM, Holland AJA. Eur J Pediatr 2020; 179(1): 9–16
A summary of studies on topical and intralesional corticosteroids, topical immunomodulators, ozonated olive oil with vitamin E acetate, preputioplasty, and circumcision.
Diagnostic criteria, severity classification and guidelines of lichen sclerosus et atrophicus
Hasegawa M, Ishikawa O, Asano Y, et al. Journal of Dermatology 2018; 45: 891–7.
Comprehensive reference for diagnosis and guidelines for management of lichen sclerosus.
Zoon’s plasma cell balanitis: clinical and dermoscopic features in pediatric patients
Chessa MA, Sechi A, Baraldi C, et al. Int J Dermatol 2018; 57: 142–4.
A case series of three pediatric patients aged 7, 8, and 13 months with Zoon balanitis demonstrated serpentine, linear-irregular, and spermatozoa-like vessels; orange-brown structureless areas; and dotted vessels on dermoscopy. The patients were treated with 4 weeks of fusidic acid cream and betamethasone twice daily. Two patients experienced resolution, while one required a shift to 1% pimecrolimus cream twice daily, which led to resolution.
Clinical features and management of recurrent balanitis: association with atopy and genital washing
Birley HD, Walker MM, Luzzi GA, et al. Genitourin Med 1993; 69: 400–3.
Forty-three patients with recurrent balanitis were evaluated. Thirty-one patients diagnosed with irritant contact dermatitis had a greater lifetime incidence of atopy and more frequent genital hygiene habit; 90% responded to conservative treatment, use of emollient creams, and restriction of soap use.
Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus
Chi C, Kirtschig G, Baldo M, et al. J Am Acad Dermatol 2012; 67: 305–12.
Topical clobetasol propionate 0.05% applied for 3 months and mometasone furoate 0.05% applied for 5 weeks were both superior to placebo. Pimecrolimus 1% cream and clobetasol propionate 0.05% cream after 12 weeks of application were both effective at relieving pruritus and burning; there were no significant differences between clobetasol propionate and pimecrolimus. No evidence was found supporting the topical use of androgens and progesterone.
Randomized open-label trial comparing topical prescription triamcinolone to over-the-counter hydrocortisone for the treatment of phimosis
Chamberlin JD, Dorgalli C, Abdelhalim A, et al. J Pediatr Urol 2019; 15 (4): 388.e1-5.
Fifty-two boys with grades 4–5 phimosis (phimosis grade scale 0–5) were randomized to over-the-counter hydrocortisone or triamcinolone 0.1% cream with manual retraction of the foreskin twice daily for 12 weeks. Hydrocortisone and triamcinolone yielded 61.5% and 68.4% success rates at 12 weeks, which were not statistically different.
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