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Balanitis Circumscripta Plasmacellularis Workup

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
Updated: Feb 09, 2016

Laboratory Studies

The diagnosis of balanitis circumscripta plasmacellularis (plasma cell balanitis) is confirmed by distinctive histologic findings upon skin biopsy.


Imaging Studies

A 2013 study assessed the possibility of using reflectance confocal microscopy (RCM), a tool used to perform in vivo imaging, to help differentiate balanitis (balanitis circumscripta plasmacellularis [plasma cell balanitis] perhaps included) and carcinoma in situ (CIS) instead of using the standard of care, biopsy. Findings used in the assessment were histologic, clinical, and RCM data. Outcome measures were overall death, disease-specific death, nodal metastasis, and local recurrence. Results indicated that RCM findings were effective in differentiating balanitis and CIS, suggesting a possible role for avoiding biopsy in the delicate area.[18]



Skin biopsy may be necessary for histologic studies.


Histologic Findings

Skin biopsy of the balanitis circumscripta plasmacellularis (plasma cell balanitis) lesion reveals suggestive, if not distinctive, changes in the epidermis and dermis. There is epidermal thinning with effacement of the rete ridges. This atrophy may be significant enough to reveal ulceration of the epidermis. Diamond-shaped or lozenge keratinocytes are common. There is also uniform spongiosis, known as "watery spongiosis." Dyskeratotic keratinocytes are not uncommon.

Dermal findings include a dense subepidermal infiltrate with a predominance of plasma cells. Vascular proliferation with erythrocyte extravasation and hemosiderin deposits is noted frequently.

Alessi et al[19] analyzed this condition and found that a small group of previously unclassified cases showed common clinical and histopathological features. All of the patients were uncircumcised, and all had long-standing asymptomatic erythematous plaques on the balanopreputial sac. No correlation with sexual intercourse was reported. Histologically, all the specimens showed a thinned and spongiotic epithelium, a bandlike infiltrate of lymphocytes, and histiocytes. A variable number of plasma cells were present in the upper part of the submucosa. The authors concluded that these cases fell within a spectrum of inflammatory noncicatricial disorders, ranging from almost pure lymphohistiocytic forms to forms that fulfill all criteria for balanitis circumscripta plasmacellularis of Zoon. They proposed the term idiopathic inflammatory noncicatricial balanoposthitis.

Weyers et al[20] studied 45 cases of balanitis of Zoon clinically and histopathologically. They noted that slight epidermal acanthosis and parakeratosis and a patchy lichenoid infiltrate of lymphocytes and some plasma cells were present early. They also reported epidermal atrophy and erosions, a scattering of neutrophils in the upper reaches of the epidermis, scant spongiosis, RBC extravasation, and a much denser infiltrate with many plasma cells as late findings in one case. Late changes included subepidermal clefts, ulceration, superficial dermal marked fibrosis, and a marked increase of siderophages.

These findings suggested that balanitis circumscripta plasmacellularis (plasma cell balanitis) results from irritation or mild trauma involving scantly keratinized skin in a moist environment. Weyers et al also noted that balanitis of Zoon may be found superimposed on the skin eruptions of other types of cutaneous pathology and that it can alter such histopathology. Some eruptions diagnosed as balanitis circumscripta plasmacellularis (plasma cell balanitis) included allergic contact dermatitis, psoriasis, lichen planus, and Bowen disease. Their conclusion was that balanitis circumscripta plasmacellularis (plasma cell balanitis) is simply a reaction pattern.

Of the 112 persons with a clinical diagnosis of balanitis circumscripta plasmacellularis (plasma cell balanitis) studied by Kumar et al,[11] 96 underwent histopathological tissue analysis. Histological features included (1) epidermal edema; (2) a dense upper dermal band of chronic inflammatory cells, including many plasma cells; (3) dilated capillaries and extravasated red blood cells; and (4) hemosiderin deposition.

In 2010, at the University of Virginia,[21] 28 cases of Zoon-like lesions, 22 cases of lichen planus, 8 cases of plasmacytoma, and 2 cases of syphilis were reviewed. The authors tabulated 24 histologic data points including 12 epidermal and 12 dermal criteria. In Zoon-like lesions, histopathologic findings, irregardless of location, included superficial cutaneous erosions and basal vacuolar alteration. Epidermal lozenge-shaped keratinocytes with dense dermal inflammatory infiltrate composed of predominantly dermal plasma cells, with scattered neutrophils and lymphocytes and upper dermal fibrosis were often seen as well. The authors suggested the generic term idiopathic lymphoplasmacellular mucositis-dermatitis be considered to cover the lymphoplasmacellular infiltrates in the skin and mucosal surfaces.

Contributor Information and Disclosures

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Nothing to disclose.


George C Keough, MD Chief, Clinical Assistant Professor, Department of Medicine, Dermatology Service, Eisenhower Army Medical Center

George C Keough, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association

Disclosure: Nothing to disclose.

Daniel S Lehman, MD Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center

Disclosure: Nothing to disclose.

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