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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 435-437
The role of erbium: Yag laser in the management of zoon's balanitis - a case report with mini review


From the Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Web Publication2-Nov-2022

Correspondence Address:
Alpana Mohta
From the Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_471_22

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How to cite this article:
Mohta A, Ghiya BC, Mehta RD. The role of erbium: Yag laser in the management of zoon's balanitis - a case report with mini review. Indian J Dermatol 2022;67:435-7

How to cite this URL:
Mohta A, Ghiya BC, Mehta RD. The role of erbium: Yag laser in the management of zoon's balanitis - a case report with mini review. Indian J Dermatol [serial online] 2022 [cited 2022 Nov 26];67:435-7. Available from: https://www.e-ijd.org/text.asp?2022/67/4/435/360330




Sir,

Zoon's balanitis (ZB) was described for the first time by Zoon in 1952 in eight men having chronic balanitis who were initially misdiagnosed as having erythroplasia of Queyrat. However, their biopsy specimen revealed plasma cell infiltration throughout the thickness of the lesion with no cellular atypia. The condition, therefore, came to be known as plasma cell balanitis or balanitis circumscripta plasmacellularis.[1] Herein, we describe a case of ZB successfully managed with two sessions of erbium: YAG laser.

A 58-year-old heterosexual immunocompetent male presented to us with a complaint of development of asymptomatic red lesions over his glans for 10 months. The patient was monogamous. All his routine investigations including those for serology of various sexually transmitted diseases were unremarkable with negative fungal culture, and Gram stain.

On clinical examination, the patient was uncircumcised. Foreskin retraction revealed that there was the presence of a confluence, erosive erythematous plaque over glans of penis, coronal sulcus and prepuce with a typical 'Cayenne pepper appearance' [Figure 1]. His differential diagnoses were ZB, immunobullous dermatoses, candidiasis, balanoposthitis, lichen sclerosus and erythroplasia of Queyrat. Histopathology revealed parakeratosis and a dense plasma cell infiltration in the submucosa. The patient was diagnosed with ZB. Over the course of the next 6 months, various topical agents like mupirocin, clotrimazole, tacrolimus and topical corticosteroids were prescribed in combination and on rotation with little to no response.
Figure 1: Deep red, shiny, confluent plaque on the glans and foreskin

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After 6 months of treatment non-responsiveness, a session of erbium: YAG fractional laser was planned. After injecting a local anaesthetic, fractional erbium: YAG laser ablation was done with 15 J/cm2 fluence, 5 mm spot size, 8 Hz frequency with 50% overlapping. Topical mupirocin was applied for the next 5 days. The session was repeated twice at monthly intervals followed by a good response in the form of the disappearance of smooth-faced erythematous plaques and the appearance of normal mucosa [Figure 2]. There was no recurrence in the next 6 months' follow-up.
Figure 2: Good clearance with minimal remanent erythema after two sessions of Er:YAG laser

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ZB is an ailment of middle-aged uncircumcised men and arises due to the occlusive effect of urine and smegma retention. The role of bacterial infections, superantigens, mycobacterium smegmatis, friction, heat, inflammatory response in the foreskin, hypospadias, poor hygiene, Ig-E hypersensitivity, polyclonal B cell stimulation, premalignant cellular atypia and B and T cell non-specific stimulation is also suggested.[2],[3]

Although often asymptomatic, sometimes the patient complains of pain and blood-soiling of clothes. The disease runs a chronic course. A similar entity has also been described in women which is known as vulvitis circumscripta plasmacellularis.[3]

In the past, the most popular management option was surgical excision. Circumcision is both preventative and curative. It helps in removing the root of chronic inflammation all together. Topical agents include fusidic acid, 0.03–0.1% tacrolimus, 0.1% pimecrolimus, 2% mupirocin, 1% clotrimazole, topical griseofulvin and corticosteroids.[3] Lately, newer modalities like photodynamic therapy and laser management have also come into the picture for ZB.

Fractional lasers like carbon dioxide and erbium: YAG are also being increasingly used for managing refractory cases of ZB. The erbium:YAG laser provides a superficial yet precise epidermal and dermal ablation using low thermal energies. There is no risk of scarring with superficial resurfacing and the healing downtime is also greatly reduced. Erbium:YAG laser for ZB was used for the first time in 2002 with promising results. Later in 2010, Wollina et al. found Er: YAG to be an effective, reliable and minimally invasive therapy in chronic non-scarring balanitis.[3],[4],[5]

In our case, we found Er:YAG to be a reliable option for the management of chronic and resistant ZB with no adverse events. However, controlled studies with more subjects are required to establish its role further.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zoon JJ. Chronic benign circumsript plasmocytic balanoposthitis. Dermatologica 1952;105:1-7.  Back to cited text no. 1
    
2.
Davis DA, Cohen PR. Balanitis circumscripta plasmacellularis. J Urol 1995;153:424-6.  Back to cited text no. 2
    
3.
Bari O, Philip RC. Successful management of Zoon's balanitis with topical mupirocin ointment: A case report and literature review of mupirocin-responsive balanitis circumscripta plasmacelluaris. Dermatol Ther (Heidelb) 2017;7:203-10.  Back to cited text no. 3
    
4.
Wollina U. Ablative erbium: YAG laser treatment of idiopathic chronic inflammatory non-cicatricial balanoposthitis (Zoon's disease)--A series of 20 patients with long-term outcome. J Cosmet Laser Ther 2010;12:120-3.  Back to cited text no. 4
    
5.
Wollina U. Erbium-YAG-laser treatment of balanoposthitis chronica circumscripta benigna plasmacellularis Zoon. Med Laser Appl 2006;21:23-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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