Doi:10.1016/j.mla.2005.11.002

Medical Laser Application 21 (2006) 23-26 Erbium-YAG-laser treatment of Balanoposthitis chronica circumscriptabenigna plasmacellularis Zoon Department of Dermatology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden,Friedrichstrasse 41, 01067 Dresden, Germany Received 1 August 2005; accepted 28 November 2005 Balanoposthitis chronica circumscripta benigna plasmacellularis Zoon is not an uncommon disease affecting males and females. In males the disease is restricted to non-circumcised subjects. Topical treatment is non-effective and doesnot induce complete remissions. Circumcision is the treatment of choice for males. An erbium:YAG laser was used asan alternative to surgery. Eleven males with various pretreatments were included. The diagnosis of Zoon' disease wasconfirmed by histology. In the majority of cases topical anaesthesia with EMLA cream was efficient, only two patientsneeded an infiltration with lidocaine. Laser therapy was performed with overlapping pulses (1.6 or 3 mm) and impulseenergies between 400 and 800 mJ resulting in fluences between 11.3 and 20 J/cm2. In all patients a complete remissionwas achieved, in seven with a single and in four with a second laser application. During the follow-up period of 3-28months (mean 10.7 months) there was no relapse. The treatment was well tolerated and without severe adverse effects.
In conclusion, erbium:YAG laser is a minimal invasive, effective and safe treatment for Zoon's disease.
r 2006 Elsevier GmbH. All rights reserved.
Keywords: Balanoposthitis chronica circumscripta benigna plasmacellularis zoon; Laser; Erbium:YAG-laser; Balanitis praepuce and the glans penis, among the other half theglans penis is mostly affected In 1952, Zoon described a chronic circumscribed but A biopsy should be taken to exclude other types of completely benign type of balanoposthitis in non- chronic balanoposthitis including penile carcinoma circumcised males The disease is quite common The earliest histopathologic changes are a thickening of among older men but some cases have been observed in the epidermis with parakeratosis and a patchy lichenoid the age group below 35 years. More recent investiga- dermal infiltrate consisting of lymphocytes and plasma tions, however, have questioned the nature of Zoon's cells. In more advanced cases there is an epidermal disease and classified the typical Zoon as one of the atrophy, sometimes with vulnerability and superficial possible presentations in a spectrum of chronic inflam- erosion. The dermal infiltrate becomes much denser and matory non-cicatrical balanoposthitis In about half the percentage of plasma cells is increased. Later on of the cases the inflammation involves both the inner there is dermal fibrosis with numerous siderophages anda further epidermal thinning. There may be alsosubepidermal clefts and erosions Zoon's disease can be understood as a non-specific response pattern to Tel.: +49 351 4801210; fax: +49 351 4801219.
E-mail address: wollina-uw@khdf.de.
1615-1615/$ - see front matter r 2006 Elsevier GmbH. All rights reserved.
doi:10.1016/j.mla.2005.11.002 U. Wollina / Medical Laser Application 21 (2006) 23-26 The course can be over many years (up to 47 years) After ablation a combination of a topical corticoster- and topical treatment usually is completely ineffective.
oid and fusidic acid (Fucicortr cream, Leo Pharma, The method of choice therefore is circumcision with a Neu-Isenburg, Germany) was used by the patients for a couple of days. A complete remission was defined ascomplete absence of erythematous, smooth faced, ''wet''looking patches or erosions.
Eleven non-circumcised males in the age between 34 and 83 years (mean 62.1 years) with a histopathologi- The fluence used was dependent on the clinical cally proved diagnosis of Zoon's disease were included.
presentation. The more atrophy the less fluence was All of them had at least three topical pretreatments with used. The laser treatment was effective. A complete antimycotics/antibacterials, corticosteroids or combined remission was obtained with a single laser application in ointments. Topical calcineurin inhibitors were used in seven patients, four needed a second therapy, mostly two patients. Despite some temporary improvement because bleeding during the first therapy limited laser there was no remission. The medical history of Zoon's efficacy. Capillary bleeding was seen in nine of 11 disease varied between 1 and 5 years (mean 2.2 years). In patients which could be stopped easily by topical several patients there were concomitant diseases like application of policresulene (Albothyl, Altana Pharma diabetes mellitus type II (n ¼ 1), dermatitis/eczema Germany, Konstanz). Treatment was well tolerated.
(n ¼ 3) or asthma/bronchitis (n ¼ 2).
Complete re-epithelization was achieved within 6-10 Zoon's disease involved the glans penis in all cases, days depending on the grade of epithelial atrophy before the inner prepuce was affected in four (30%) and seven laser treatment. There was no unwanted side effect such (58.3%) had lesions in the balanoprepuctial fold. The as delayed healing, infection, scar formation or meatus glans area involved ranged from 50% to 90% (mean stricture. In case of Zoon's lesions on the inner prepuce and the glans penis we did not observe any fusion or There was no need for general anaesthesia. Two phimosis. After wound healing there was no impairment patients were treated with lidocaine injection (Xyloci- of sexual functions including intercourse.
tinr, mibe Jena/Jenapharm, Jena, Germany), the other All patients had a complete remission which was needed topical EMLAr cream (Astra Zeneca, Wedel, stable during the follow-up period of 3-28 months Laser therapy was realized with an erbium:YAG laser (Dermablate MCL 29; Asclepion-Meditec, Jena, Ger-many). The focus diameter was adapted to the individual situation (1.6 or 3 mm). The frequency was8 Hz and the impulse energy between 400 and 800 mJ Zoon's disease can be found on the outer genitals in resulting in a fluence of 11.3-20 J/cm2. Ablative treat- males and females In males Zoon's disease occurs ment was done by overlapping pulses.
exclusively in non-circumcised subjects. In cases of Summary of patients with Zoon's disease Xylo-xylocitine (lidocaine) 1% ; EMLA-EMLA cream.
U. Wollina / Medical Laser Application 21 (2006) 23-26 infectious disease, pharmacologic therapy is effective, efficacy of the erbium:YAG laser should not be different but not in classical Zoon's disease. Circumcision therefore may be seen as a ''causative'' treatment inmales that is for sure superior to topical drugs.
Side effects of circumcision in adults are rare in the hand of the experienced but may happen. The most frequentinclude post-surgical pain, swellings and bleeding.
Erbium:YAG-Laserbehandlung der Balanophosthitis Disturbances of scar formation may interfere with sexual function. Wound infection is rare. Allergies tolocal anaesthetics, sutures, disinfectants or wound Die Balanoposthitis chronica circumscripta benigna dressings may develop. Some patients therefore refuse plasmacellularis Zoon ist keine seltene Erkrankung, die surgery others may suffer from concomitant disease that Ma¨nner wie Frauen betreffen kann. Unter den Ma¨nnern bear a high risk for surgery. Surgery is not an accepted ist sie ausschließlich bei denen ohne Beschneidung zu finden. Die topische Behandlung ist nicht effektiv und There is a need for less invasive but comparable vermag keine Komplettremissonen zu induzieren. De- effective treatments. The use of ablative lasers is a shalb gilt die Zirkumzision als Therapie der Wahl bei promising tool to remove the diseased tissue that can be Ma¨nnern. Als Alternative setzten wir den Erbium:YAG- replaced by normal epithelia during wound healing.
Laser ein. Elf Ma¨nner mit diversen Vorbehandlungen A copper vapour laser has also been employed und histologisch gesicherter Diagnose wurden beru¨ck- successfully in a single case from Copenhagen, Denmark sichtigt. In der u¨berwiegenden Mehrzahl der Fa¨lle The CO2 laser has been used occasionally to treat genu¨gte die topische Ana¨sthesie mit EMLA-Creme, bei Zoon's disease as well as other types of chronic 2 Patienten war eine Infiltrationsanalgesie mit Lidocain balanoposthitis for years Because of the pain erforderlich. Die Laserbehandlung wurde mit u¨berlap- local anaesthesia with injectable anaesthetics such as penden Pulsen (Durchmesser 1.6 oder 3 mm) und einer lidocaine is necessary. Superpulsed CO2 is preferable Impulsenergie zwischen 400-800 mJ entsprechend 11,3 because of the limited lateral damage of dermal bis 20 J/cm2 vorgenommen. Bei allen Patienten konnte eine Komplettremission erzielt werden; bei 7 mit einer The erbium:YAG laser offers an ablative treatment einzigen Behandlung, bei 4 Ma¨nnern war eine Zweitla- with precise and superficial tissue removal, low thermal serung notwendig. In der Nachbeobachtungszeit, die injury, a very low risk of scar formation, rapid healing zwischen 3 und 28 Monaten lag (Mittel 10,7 Monate), and low pain. The erbium:YAG laser has also wurden keine Ru¨ckfa¨lle der Balanoposthitis beobachtet.
been used to increase the delivery of topical anaes- Die Behandlung wurde gut toleriert, schwere Nebenwir- kungen traten nicht auf. Zusammenfassend stellt die There is one published case of Zoon's balanitis treated Erbium:YAG-Laserung beim Mb. Zoon eine minimal with an erbium:YAG laser successfully These invasive, effektive and sichere Behandlung dar.
authors suggested erbium:YAG laser treatment to be r 2006 Elsevier GmbH. All rights reserved.
the treatment of choice in plasmacellular balanitis andposthitis.
We performed ablative erbium:YAG treatment of benigna plasmacellularis Zoon; Laser; Erbium:YAG-Laser, Zoon's disease in 11 non-circumcised males. When we started we used lidocaine injections but changed totopical EMLA cream. EMLA cream was efficient toreduce the pain in all patients. This seems to be an advancement compared to CO2 lasers. The treatmentwas well tolerated and effective in a single setting with a Tratamiento con la'ser Erbium-YAG para Balanopostitis single pulse mode in most cases. No severe side effects cro'nica circunscrita benigna plasmacellularis Zoon like scar formation, infections, meatus strictures orimpairment of sexual function occurred. The healing La balanopostitis cro'nica circunscrita benigna plas- was rapid and complete in most patients within 1-2 macellularis Zoon no es una rara enfermedad que puede weeks. During follow-up there was no recurrence, but afectuar tanto a hombres como a mujeres. Entre los longer follow-up periods over a couple of years may be hombres se da exclusivamente en los no circuncidados.
necessary for final conclusions. In a study on 15 males El tratamiento to'pico no es efectivo y no es capaz de with Mb. Zoon treated with CO2 laser a relapse was inducir remisiones completas. Por eso, la circuncisio'n es considerada la terapia de eleccio'n para hombres.
Although we did not perform the laser treatment for Usamos el la'ser Erbium:YAG como opcio'n. Once Mb. Zoon in females it might be assumed that the hombres sometidos a diversos pre-tratamientos y con U. Wollina / Medical Laser Application 21 (2006) 23-26 diagno'stico demostrado histolo'gicamente fueron esco- [6] Kumar B, Sharma R, Rajagopalan M, Radotra BD.
gidos para este estudio. La anestesia to'pica con crema Plasma cell balanitis: clinical and histopathological EMLA fue suficiente en la mayori'a de los casos, y la features-response to circumcision. Genitourin Med analgesia de infiltracio'n fue necesaria en 2 pacientes. El tratamiento con la'ser fue realizado con pulsos sobre- [7] Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of Zoon: a clinicopathologic study of 45 cases. Am J puestos (dia'metro 1.6 o' 3 mm) y una energi'a de pulso entre 400-800 mJ correspondiendo a 11,3-20 J/cm2. Se [8] Pastar Z, Rados J, Lipozencic J, Skerlev M, Loncaric D.
observo' una remisio'n completa en todos los pacientes.
Zoon plasma cell balanitis: an overview and role of Un solo tratamiento de la'ser fue suficiente en 7 pacientes, y 4 pacientes requirieron un segundo trata- miento. En el tratamiento ulterior, que duro' entre 3 y 28 [9] Souteyrand P, Wong E, MacDonald DM. Zoon's meses (una media de 10,7 meses), no se observo' ninguna balanitis (balanitis circumscripta plasmacellularis). Br J recai'da de Balanopostitis. El tratamiento fue bien tolerado, y no se observaron efectos secundarios graves.
[10] Yoganathan S, Bohl TG, Mason G. Plasma cell balanitis En resumen, el tratamiento de la'ser con Erbium:YAG and vulvitis (of Zoon). A study of 10 cases. J Reprod Med para Mb. Zoon es seguro, efectivo y mi'nimamente [11] Ferrandiz C, Ribera M. Zoon's balanitis treated by circumcision. J Dermatol Surg Oncol 1984;10:622-5.
r 2006 Elsevier GmbH. All rights reserved.
[12] Haedersdal M, Wulf HC. Plasma cell balanitis treated with a copper vapour laser. Scand J Plast Reconstr Surg Palabras clave: Balanopostitis cro'nica circunscrita benigna plasmacellularis Zoon; la'ser; Erbium:YAG; Balanitis [13] Conejo-Mir JS, Munoz MA, Linares M, Rodi'guez L, Serrano A. Carbon dioxide laser treatment of erythro- plasia of Queyrat: a revisited treatment to this condition.
J Eur Acad Dermatol Venereol 2005;19:643-4.
[1] Zoon JJ. Baloposthite chronique circonscrite benigna a` [14] Retamar RA, Kien MC, Chouela EN. Zoon's balanitis: plasmocytes. Dermatologica 1952;105:1-7.
presentation of 15 patients, five treated with a carbon [2] Alessie E, Coggi A, Gianotti R. Review of 120 biopsies dioxide laser. Int J Dermatol 2003;42:305-7.
performed on the balanopreputial sac. From Zoon's [15] Canaglia RJ. Erbium:YAG laser skin resurfacing. Facial balanitis to the concept of a wider spectrum of Plast Surg North Am 2004;12:373-7.
inflammatory non-cicatrical balanoposthitis. Dermatol- [16] Coates J. Basic physics of erbium laser resurfacing. J [3] Altmeyer P, Kastner U, Luther U. Die Balanitis/ [17] Yun PL, Tachihara R, Anderson RR. Efficacy of Balanoposthitis chronica circumscripta benigna plasma- erbium:yttrium-aluminium-garnet laser-assisted delivery cellularis-Entita¨t oder Fiktion? Hautarzt 1998;49:552-5.
of topical anesthetic. J Am Acad Dermatol 2002;47: [4] Davis DA, Cohen PR. Balanitis circumscripta plasma- cellularis. J Urol 1995;153:424-6.
[18] Albertini JG, Holck DE, Fraley MF. Zoon's balanitis [5] Ewards S. Balanitis and balanoposthitis: a review.
treated with erbium: YAG laser ablation. Lasers Surg

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