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THE JOURNAL OF UROLOGY Vol. 153,424-426,February 1995
UROLOCICAL
Copyright 0 1995 by AMERICAN ASSOCIATION,INC. Printed in U.S.A.

BALANITIS CIRCUMSCRIPTA PLASMACELLULARIS

DAVID A. DAVIS AND PHILIP R. COHEN*
From the University of Colorado Medical School, Denver, Colorado, and the Departments of Dermatology and Pathology, University of
Texas Medical School at Houston and Department of Medical Specialties, Section of Dermatology, University of Texas M . D. Anderson
Cancer Center, Houston, Texas

ABSTRACT

Balanitis circumscripta plasmacellularis typically affects the glans penis andlor prepuce, and
presents as chronic shiny smooth red-orange plaques. We report on an uncircumcised man with
2 moist red-orange lesions of balanitis circumscripta plasmacellularis on the glans and penile
shaft, which were refractory to topical therapy and systemic antibiotics, and review the litera-
ture. Clinical morphology, microscopic features, differential diagnosis, postulated etiologies and
treatments are discussed. When balanitis circumscripta plasmacellularis is suspected clinically,
diagnosis can be readily confirmed by microscopic examination of the lesion. Differentiating this
lesion from similar lesions is essential since it is benign and can be treated relatively easily by
circumcision.
KEY WORDS:balanitis, penis, circumcision, plasma cells
In 1952 Zoon reported on 8 men with chronic balanitis hemosiderin were also noted in the dermis (fig. 2). Diagnosis
whose condition had been diagnosed previously as erythro- was balanitis circumscripta plasmacellularis based on the
plasia of Queyrat.' However, histological examination re- clinicopathological correlation of the morphological features
vealed a distinctive inflammatory infiltrate composed pre- and histological changes of the lesion.
dominantly of plasma cells. Characteristic signs of The lesions were unresponsive to several topical medica-
erythroplasia and cytological atypia were absent, and the tions, including 1.0% hydrocortisone cream, 1.0% clotrima-
behavior of the lesions was benign. Zoon termed this condi- zole cream and 0.1% triamcinolone cream. Infectious lesions
tion chronic circumscribed plasma cell balanoposthitis. Sub- of the genitalia, such as syphilis, which are often character-
sequently it has been referred to as plasma cell balanitis of ized similarly by a plasma cell infiltrate in the dermis re-
Zoon and balanitis circumscripta plasmacellularis. We report spond to systemic tetracycline therapy. Therefore, a trial of
on a patient with balanitis circumscripta plasmacellularis, 500 mg. tetracycline 3 times daily was initiated. No clinical
discuss the clinical and histological features of this condition, change in the lesions was observed after 3 continuous months
and review differential diagnosis, treatments and pathogen- of therapy and the drug was discontinued. Because the pa-
esis. tient refused circumcision, the lesions are monitored clini-
cally at followup.
CASE REPORT
DISCUSSION
A 65-year-old obese white man with insulin-dependent
type I1 diabetes mellitus presented to his urologist with dif- Balanitis circumscripta plasmacellularis primarily occurs
ficulty in voiding. An asymptomatic 1.5 cm. reddish-or- in elderly uncircumcised men. The condition typically pre-
ange, well circumscribed moist plaque on the shaft of the sents as shiny smooth circumscribed plaques with a red-
penis and a smaller similar lesion on the glans were observed orange hue on the glans penis andlor prepuce. The lesions
(fig. 1). Because of abdominal obesity, the patient could not tend to be chronic and are often present for an average of 1to
see this area of the body and, therefore, he had not previously 2 years with minimal change before diagnosk2 Symptoms
noticed these penile lesions. are generally absent but mild pruritus or tenderness may
The patient had not been sexually active for at least the
previous 10 years. General systemic physical examination
was otherwise unremarkable, and inguinal lymphadenopa-
thy was not present. Palms, soles, and oral and perianal
mucosa were unremarkable. The remainder of the cutaneous
examination, including routine blood analysis and urinalysis,
was within normal limits and rapid plasma reagin was neg-
ative. Potassium hydroxide preparation of the lesion was
negative for fungal elements. Gram's, Giemsa and silver
stains of a lesional smear preparation were negative for
bacteria. Cultures from the lesion were negative for bacteria,
fungi and herpes simplex virus.
Microscopic examination of a lesional skin biopsy demon-
strated an acanthotic epidermis with flattening of the epider-
mal rete ridges. A dense band-like inflammatory infiltrate of
predominantly plasma cells filled the papillary dermis and
extended into the reticular dermis. Numerous deposits of

Accepted for publication April 8, 1994.

* Re uests for reprints: Department of Dermatology, University of
Texas (Xledical School, 6431 Fannin, Suite 1.186, Houston, Texas FIG. 1. Red-orange plaques of balanitis circumscripta plasrnacel-
77030. Maris with small dark red stippling on distal penile shaft and glans.
424
BALANITIS CIRCUMSCRIPTA PLASMACELLULARIS 425
Hypospadias has been reported as a predisposing factor."
Kossard and Shumack suggested that variants of balanitis
circumscripta plasmacellularis may be related to lichen au-
reus. " Similar etiological factors have been implicated in
both diseases: as in lichen aureus the histological features of
the dermis of balanitis circumscripta plasmacellularis le-
sions may be secondary to vascular fragility and vascular
abnormalities. l5
Patients with balanitis circumscripta plasmacellularis
may request biopsy evaluation and treatment because of
anxiety and/or cosmetic disfigurement. Less commonly, dis-
comfort and irritation prompt additional investigation and
therapeutic intervention. Circumcision using local or general
anesthesia is the treatment of choice.l6 The semi-mucosal
character of the squamous epithelium that covers the inner
preputial surface and the glans disappears after circumci-
FIG.2. Pathological changes consistent with balanitis circum- sion.17Removal of this mucosal quality appears to inhibit the
scripta plasmacellularis include flattening of epidermal rete ridges,
dense dermal infiltrate of plasma cells and focal areas of hemosiderin undetermined etiological agent(s). Therefore, circumcision
deposition (arrow).A, H & E, reduced from X10. B , H & E, reduced not only permits complete resolution but also enables an
from X50. exact histopathological diagnosis to be made.
Baldwin and Geronemus reported the successful ablation
of balanitis circumscripta plasmacellularis using a carbon
O C C U ~ .The
~ surface of the plaque is usually slightly moist dioxide laser. In contrast, radiotherapy and electrodesicca-
with small dark red stippling called "cayenne pepper tion have been used with negligible or no improvement.10.''
Presumptive clinical diagnosis must be confirmed on Nonsurgical treatments are generally ineffective in achieving
biopsy. Histological changes affecting the epidermis and resolution.'0 Topical antibiotics and antifungal therapies are
dermal vasculature are usually distinctive. Pathological almost universally without benefit but long-term treatment
features may include atrophy of the epidermis, loss of the with topical corticosteroid creams and ointments may
rete ridges and spongiosis. Individual epidermal cells in achieve symptomatic relief in some casesz1 No improvement
the supra-basal layers have been described as diamond was noted in our case with systemic tetracycline or various
shaped or lozenge keratinocytes.2 Additional pathological topical agents.
findings may include a dense inflammatory infiltrate of
predominantly plasma cells below the epidermis and a CONCLUSION
proliferation of vertically oriented vessels. Hemosiderin
deposition and erythrocyte extravasation are often ob- Balanitis circumscripta plasmacellularis typically occurs
served as well. Importantly, keratinocyte dysplasia and in elderly uncircumcised men and is characterized by chronic
frank vesiculation are absent.' shiny, smooth, red-orange circumscribed plaques with small
Disorders that can clinically mimic balanitis circumscripta dark red stippling. Microscopically there is a dense plasma
plasmacellularis include allergic contact dermatitis, candidi- cell infiltrate with vertically oriented vessels in the dermis
asis, erythroplasia of Queyrat (squamous cell carcinoma in and epidermal atrophy with flattened rete ridges, spongi-
situ or Bowen's disease of the glans penis), fixed drug erup- osis and lozenge keratinocytes. Etiology of balanitis circum-
tions, herpes simplex virus, lichen planus, pemphigus vul- scripta plasmacellularis is likely to be multifactorial and the
garis, psoriasis vulgaris, Reiter's disease and secondary current treatment of choice is circumcision.
syphili~.~.Analogous lesions of the female genitalia are
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