Zoon’s balanitis treated with imiquimod 5% cream

ARTICLE

Auteur(s) : Barbara Marconi¹, Anna Campanati¹, Oriana Simonetti¹, Andrea Savelli¹, Luca Conocchiari¹, Alfredo Santinelli², Eleonora Pisa², Annamaria Offidani¹

¹Department of Dermatology, Polytechnic University of Marche, United Hospitals, n.71 Conca St., 60126 Torrette-Ancona, Italy
²Section of Pathological Anatomy, Polytechnic University of Marche, United Hospitals, n.71 Conca St., 60126 Torrette-Ancona, Italy

We report a 59-year-old man suffering from Zoon’s balanitis (ZB) for three years. The man was not circumcised and was unresponsiveness to mild and potent topical corticosteroids. He received topical treatment with imiquimod 5% cream, 3 times a week for 12 weeks. During this period the patient did not develop any severe local reactions causing a treatment discontinuation and, after 12-weeks, he showed a complete clinical healing.

Zoon’s balanitis (or plasma cell balanitis or balanitis circumscripta plasmacellularis) is a disorder typical of middle-aged and older uncircumcised males [1]. It is a chronic, reactive, irritant mucositis, without precancerous tendencies, often associated with mild phymosis, whose ethiopathogenesis still remains unclear. Clinically ZB is always asymptomatic, scarcely palpable, and typically appears as a well-demarcated, moist, bright red or brown patch, located on the dorsal portion of the glans and frequently also in the adjacent prepuce. Edema, ulcerations or eschars are usually absent [2]. Zoon’s balanitis represents a therapeutic challenge, for this reason we describe our experience with the use of imiquimod.

A 59-year-old man was directed to our clinic because of a red patch which had appeared on the glans of his penis three years before; this lesion was asymptomatic, well-demarcated and glistening (figure 1A). At a histological level, the epidermis was thinned, spongiotic with lozenge- or diamond-shaped keratinocytes; the granular and corneous layers were absent. A dense, band-like, lymphohistiocytic and plasma cell-rich dermal infiltrate, with occasional neutrophils and eosinophils, was also evident (figures 1B, C). Blood vessels were dilated and increased in number with extravasation of red blood cells and hemosiderin deposition. One year before our observation, the patient had applied mild and potent topical corticosteroids (betametasone valerate 0.1% and clobetasol 17-propionate 0.05%) to his lesions, without any improvement. We decided to treat the patient with imiquimod 5% cream, 3 times a week. After 12 weeks the patient showed a complete clinical healing with only mild inflammatory local side effects (figure 1D).

Therapy of Zoon’s balanitis is not standardized: circumcision represents the most useful, curative and definitive treatment even if topical application of a mild or potent corticosteroid can offer improvement of the disorder, without persistent clinical healing. Some evidence regarding the beneficial use of carbon dioxide laser, pimecrolimus and tacrolimus has been reported in literature [3, 4].

Imiquimod (IQ) is an immune response modifying agent; its mechanism of action is mainly related to the binding and stimulation of Toll-like receptors (TLRs), located on the surface of antigen-presenting cells; it induces the synthesis and release of several pro-inflammatory cytokines, such as interferon-alpha (IFN-α), tumor necrosis factor-alpha (TNF-α) and interleukins 6 and 12 (IL-6, IL-12), which stimulate the innate and acquired immune pathways, producing an upregulation of antiviral and antitumor activity. Imiquimod 5% cream (IQ 5%) has been used for the treatment of some dermatologic disorders in which the immune system plays an important role in regression of the disease [5]. Nasca et al. described treatment of a Zoon’s balanitis with IQ 5% cream; they obtained a complete clinical but not histological resolution of disease [6].

In our case, the patient had failed to respond to conventional topical corticosteroid therapy and, unlike a previous report from Micali et al., he developed only a mild local inflammatory reaction, thus he applied the cream uninterruptedly for the whole period of treatment and he obtained a complete clinical healing in only 12 weeks, persisting for six months after the discontinuation of the therapy. The positive outcome obtained leads us to suppose that imiquimod may play an important role in the treatment of Zoon’s balanitis. Further clinical trials will undoubtedly be needed to confirm our result and to assess proper doses and duration of therapy.

Acknowledgements

References

2 Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology 7^th edition, vol. 4, 68: 18-19.

3 Retamar RA, Kien MC, Chouela EN. Zoon’s balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol 2003; 42: 305-7.

4 Bardazzi F, Antonucci A, Savoia F, Balestri R. Two cases of Zoon’s balanitis treated with pimecrolimus 1% cream. Int J Dermatol 2008; 47: 198-201.

5 Lacarrubba F, Nasca MR, Micali G. Advances in the use of topical imiquimod to treat dermatologic disorders. Ther Clin Risk Manag 2008; 4: 87-97.

6 Nasca MR, De Pasquale R, Micali G. Treatment of Zoon’s balanitis with imiquimod 5% cream. J Drugs Dermatol 2007; 6: 532-4.