It presents as symmetrical, well-marginated, erythematous, shiny plaques with multiple pinpoint redder spots, “cayenne pepper spots” involving the glans, prepuce, or both. Vegetative, erosive and “multiple” lesion variants have also been reported. Usually, the condition is asymptomatic, though pruritus may be present.

The course tends to be chronic and may persist for months to years, and sometimes poorly responsive to topical treatment. 

Recently, dermoscopic findings in Zoon balanitis have been described in 11 patients, which include focused curved vessels (100%) in different shapes, including serpentine (100%), convoluted (45 % to 50%), chalice-shaped (27.3% to 25%); orange-brownish structureless areas (75% to 81%), linear irregular blurry vessels (36.4% to 37.5%) and dotted vessels (25% to 27.3%). These findings might assist the clinical diagnosis of Zoon balanitis, distinguishing it from its main differential diagnoses, such as erythroplasia of Queyrat, which shows scattered glomerular vessels; psoriasis, which displays regular dotted vessels and seborrheic dermatitis and non-specific balanoposthitis, usually showing linear irregular unspecific blurry vessels.[8]

The use of reflectance confocal microscopy in differentiating between balanitis and carcinoma in situ has been evaluated. Balanitis shows a nucleated honeycomb pattern and vermicular vessels scattered small bright sells and round vessels, whereas carcinoma in situ shows an atypical honeycomb pattern, disarranged epidermal pattern, and round nucleated cells.[9]

Clinicians should teach the patient adequate hygiene measures.

First-line therapy continues to be circumcision, which is the only therapy that provides long-term, full remission. Some patients often reject procedures in this sensitive area. Other options include topical steroids, calcineurin inhibitors, mupirocin, photodynamic and laser therapy, but the disease tends to relapse with the use of any of these treatments.

The use of topical steroids in the treatment of plasma cell balanitis has been used, although there is little evidence to support its use. Tang et al. reported a good response to a combination cream of oxytetracycline 3%, nystatin 100,000 units/g, and clobetasone butyrate 0.05% (Trimovate) until a complete clinical resolution was observed. Three of ten patients had recurrences within 3 months after cessation of therapy and responded to the second course of Trimovate cream. A fourth patient had three recurrences within 12 months, and each responded within a few days, and he continued on follow-up.

Calcineurin inhibitors, such as tacrolimus 0.1 and 0.3% and pimecrolimus 0.1% have been used, with complete remission after 3 to 8 weeks of therapy. However, there has been concern regarding a relationship between topical calcineurin inhibitors and carcinogenesis.

Photodynamic therapy has not yet been well established since it’s mostly based on case reports. Nevertheless, it has been considered a moderately effective and safe option for Zoon balanitis and has been used in refractory lesions.

Carbon dioxide and erbium:YAG lasers are alternatives that have shown variable outcomes. Erbium:YAG was used with a focus on mostly 3 mm. The frequency employed was 8 Hz, the impulse energy was mostly 800 mJ. In most patients, a complete re-epithelization was achieved within ten days. There was a complete clearing of lesions during follow-up (3 to 30 months). There were no major complications, including phimosis. The erbium:YAG laser offers a precise superficial ablation with low thermal injury, low risk of scarring, low pain and rapid healing.

Mupirocin 2% ointment 3 times daily for 6 weeks to 3 months, has shown temporary complete resolution in two cases. This could be explained by the possibility that Zoon balanitis might be associated with bacterial colonization or super-antigen.[10][11][12]

It includes candidiasis, contact dermatitis, fixed drug eruption, Kaposi’s sarcoma, herpes simplex virus, lichen planus, lichen sclerosus, pemphigus vulgaris, erythroplasia of Queyrat, psoriasis, secondary syphilis, and squamous cell carcinoma.

Co-infection with Candida may occur frequently.

Zoon balanitis is considered a benign entity, although isolated cases have been found in association with squamous cell carcinoma. In 1999, a case of penile carcinoma arising in a patient with Zoon balanitis was described by Joshi. In 2001, Bunker claimed that there were zoonoid changes in clinical and histological features in some cases of lichen sclerosus, lichen planus, Bowenoid papulosis, and penile cancer. These zoonoid changes could suggest that Zoon balanitis could be a premalignant condition. Further studies are necessary to establish this association.

Patients with lesions on the penis may first present to the nurse practitioner, primary care provider and internist. Since most healthcare workers are not familiar with lesions of the penis, it is wise to refer the patient to a urologist for more definitive workup. The role of the primary care providers is chiefly in prevention by educating the patient on maintenance of adequate hygiene.

First-line therapy continues to be circumcision, which is the only therapy that provides long-term, full remission. Some patients often reject procedures in this sensitive area. Other options include topical steroids, calcineurin inhibitors, mupirocin, photodynamic and laser therapy, but the disease tends to relapse with the use of any of these treatments.

The outlook for zoon balanitis is excellent; rarely it is reported that a patient may develop a dermal malignancy.[13]