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: [email protected]
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-
 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 mayorı´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-
 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 energı´a de pulso
entre 400–800 mJ correspondiendo a 11,3–20 J/cm2. Se
 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
 Souteyrand P, Wong E, MacDonald DM. Zoon’s
meses (una media de 10,7 meses), no se observo´ ninguna
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En resumen, el tratamiento de la´ser con Erbium:YAG
and vulvitis (of Zoon). A study of 10 cases. J Reprod Med
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plasmacellularis Zoon; la´ser; Erbium:YAG; Balanitis
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An article below the dotted line was written by Dr JB Lim in response to an article sent to Dr Lim by Dr Chan Boon Lye for Dr Lim to comment on the use of ordinary rice water for children who frequently have Subsequently this subject was also brought up for discussion by a group of other doctors at a banquet Dr Lim and other medical doctors and scientists recently attended at the KLCC Convention
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