Treatment of balanitis of Zoon's with tacrolimus 0.03% ointment.

Sir,

Balanitis of Zoon's (BZ) is a frequent diagnosis in mature men and lesions are generally localized on the glans but may involve the prepuce. The etiology and pathogenesis remain unknown. However, Weyers et al. have suggested that BZ is a non-specific inflammatory reactive pattern that may occur as an isolated finding or complicate other skin diseases (i.e. lichen planus, contact dermatitis, psoriasis) of the glans penis or prepuce in uncircumcised men.[1]

Histopathology is required to rule out malignancy and eryhthroplasia of queyrat, and at the same times it is quite diagnostic. Treatment modalities include topical steroids, fusidic acid, imiquimod, laser and circumcision.

Tacrolimus was the first nonsteroidal topical immunomodulator developed for treatment of atopic dermatitis. The efficacy/safety profile, lack of rebound effect and absence of tachyphylaxis are some of its attractive properties that have prompted dermatologists to prescribe it as an off label treatment of other skin conditions.

We had a 70-year-old, married, sexually inactive, uncircumcised male, who came to us with erythematous plaque present over the glans penis [Figure 1]. The lesion was asymptomatic except occasional complaints of burning sensation. The lesion was present since two years during which he had been treated with diverse topical steroids, antibiotics and antifungals without much clinical improvement. Examination revealed a shiny, erythematous plaque with a few erosions over glans penis and undersurface of prepuce. The patient was a known diabetic. Histopathological study showed features suggestive of plasma cell balanitis with no signs of malignancy. The patient was instructed to apply 0.03% tacrolimus ointment twice daily. Great improvement of the lesion was observed after two weeks of treatment. The treatment was continued for four more weeks and then tapered over the next two weeks [Figure 2]. No side effects were observed. The patient was doing well at six-month follow-up.

Figure 1

Clinical photograph showing shiny erythematous plaque over glans and meatus

Figure 2

Clinical photograph showing response after treatment

The patient had a typical clinical picture of BZ. However, biopsy was performed to rule out other skin conditions such as lichen planus, psoriasis, contact dermatitis, erythroplasia of queyart and SCC. The patient was prescribed tacrolimus ointment, prompted by the recent small case series and case reports of its use in BZ.[2-5] The patient had already been prescribed topical steroids without much benefit. He could not be given laser abalation therapy due to its expense as well as limited experience of its use for this indication and also limited availability in this part of the world. All this left us with the last option of circumcision, which the patient was advised to undergo, if tacrolimus did not prove beneficial. Tacrolimus ointment has been used in the treatment of diverse skin conditions such as atopic dermatitis, intertriginous psoriasis, lichen planus, erosive mucosal lichen planus, vitiligo, alopecia areata, contact dermatitis, seborrhoeic dermatitis etc with variable results.

The excellent and immediate clinical response obtained in our patient with 0.03% tacrolimus is encouraging and it may prove to be an effective and safe treatment for BZ.