0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Study |

Differentiation Between Balanitis and Carcinoma In Situ Using Reflectance Confocal Microscopy FREE

Edith Arzberger, MD; Peter Komericki, MD; Verena Ahlgrimm-Siess, MD; Cesare Massone, MD; Dmitry Chubisov, MD; Rainer Hofmann-Wellenhof, MD
[+] Author Affiliations

Author Affiliations: Departments of Dermatology (Drs Arzberger, Massone, and Hofmann-Wellenhof) and Environmental Dermatology and Venereology (Dr Komericki), Medical University of Graz, Graz, Austria; Paracelsus Medical University of Dermatology and Venereology, Salzburg, Austria (Dr Ahlgrimm-Siess); and Department of Dermatology and Cosmetology, Toto Pectore LLC, Almaty, Kazakhstan (Dr Chubisov).


JAMA Dermatol. 2013;149(4):440-445. doi:10.1001/jamadermatol.2013.2440.
Text Size: A A A
Published online

Importance Zoon plasma cell balanitis is a benign inflammatory disease of genital skin. It may be difficult to clinically distinguish between balanitis and carcinoma in situ (CIS); thus, a biopsy may be needed to exclude malignant disease. Reflectance confocal microscopy (RCM) is an in vivo imaging method to get morphologic information about architecture and single cells in the skin.

Objective To evaluate the ability of RCM to differentiate between balanitis and CIS compared with the gold standard histopathologic methods.

Design Observer blinded study.

Setting A referral center.

Participants Fifteen patients with balanitis or CIS.

Intervention Patients were assessed by clinical, histologic, and RCM findings. All lesions were imaged with the Vivascope 1500. In 5 cases of balanitis, the surrounding, noninvolved skin also was evaluated.

Main Outcome Measures Local recurrence, nodal metastasis, disease-specific death, overall death.

Results The clinical diagnoses showed 9 cases of balanitis and 6 cases of CIS. With histopathologic analysis, 12 cases of balanitis and cases of CIS were diagnosed, and RCM evaluation confirmed these diagnoses. The most relevant RCM criteria for CIS were atypical honeycomb pattern, disarranged epidermal pattern, and round nucleated cells. Balanitis showed a nucleated honeycomb pattern and vermicular vessels. Scattered small bright cells and round vessels were present in all lesions. The adjacent normal skin showed a typical honeycomb pattern and round papillary vessels.

Conclusions and Relevance We were able to differentiate between balanitis and CIS. Reflectance confocal microscopy may help to avoid biopsies at this sensitive site.

Figures in this Article

Zoon plasma cell balanitis is a benign idiopathic inflammatory skin disease of the glans penis, the coronal sulcus, and the inner aspect of prepuce that typically occurs in middle-aged or elderly uncircumcised men.1 Clinically, sharply demarcated, occasionally eroded patches with a glossy surface and reddish-brown color owing to erythrocytic extravasation and accumulation of siderophages are observed.26 Lesions on the glans and opposing prepuce (kissing lesions) are common. Histopathologic findings include a dense, often bandlike plasma cell infiltrate as well as prominent blood vessels and extravasated erythrocytes. The overlying epidermis can be atrophic but may also be of normal thickness with spongiosis and parakeratosis. Local infections, caused by poor hygiene, sweating, and friction are causative factors.

In some cases, there is an overlap between Zoon balanitis and chronic nonspecific balanitis both clinically and histopathologically. To simplify matters, we will use the term “balanitis” for both entities.

The clinical differentiation between balanitis and other penile dermatoses may be challenging. Erythroplasia of Queyrat (penile intraepithelial neoplasiagrade 3; carcinoma in situ [CIS]), lichen sclerosus et atrophicus, lichen planus, psoriasis, and infectious diseases are all differential diagnostic considerations. In clinically equivocal cases, a biopsy is needed to exclude a diagnosis of malignant disease, especially since CIS may develop in balanitis, possibly as a consequence of the chronic inflammation.710

Confocal laser scanning microscopy (reflectance confocal microscopy [RCM]) is an in vivo imaging method used to obtain morphologic information about both architecture and single cells in the epidermis and superficial dermis. The aim of this study was to use RCM to identify distinct in vivo morphologic criteria for balanitis and carcinoma.

Fifteen patients (mean age, 65 years [range, 48-80 years]) were evaluated by clinical, histologic, and RCM findings at the Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria (Table 1). In this prospective study (October 10, 2009–March 15, 2010) we included patients with the histopathologically confirmed diagnosis of balanitis or carcinoma. Other diseases, such as lichen sclerosus et atrophicus, psoriasis, or infections, were excluded to obtain representative data for these 2 entities only. The patients presented with atrophic to hyperkeratotic, red to brown lesions on the glans and/or inner aspect of prepuce. Seven lesions were eroded, 7 were elevated and had an infiltrated granular surface, and 1 was a verrucous plaque. The lesions had been present for several weeks in 1 case up to 15 or more years in other cases (mean, about 6 years). As mentioned, all lesions were borderline cases in which a punch biopsy was essential to confirm the diagnosis. Results from serologic testing for syphilis were negative in all cases. We also studied normal skin at the periphery of 5 cases of balanitis. Clinically, these regions were sharply delineated from the inflamed areas. Normal skin was evaluated using the same RCM criteria of this study.

Table Graphic Jump LocationTable 1. Demographic Characteristics, Clinical, Histopathologic, and Reflectance Confocal Microscopy Diagnoses

All patients gave written consent for the study, and institutional rules governing clinical investigation of human subjects were strictly followed. Approval of the local ethics committee was obtained (Figure 1).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. CONSORT diagram. RCM indicates reflectance confocal microscopy.

CLINICAL IMAGING

Baseline clinical images were taken from all lesions with a Nikon D200 digital camera (10.2 megapixels; Nikon Corp). A dermatologist (P.K.) who specializes in genital skin lesions, evaluated the digital clinical images without further information on the patient's medical history and treatment.

RCM IMAGING

All lesions were imaged with the Vivascope 1500 (Lucid Inc).11,12 After attaching the tissue ring, a dermoscopic image (“macroscopic image”) using the VivaCam was captured. This image is used for orientation during the RCM examination. The Vivascope 1500 provides thin horizontal virtual tissue sections with a field of view of up to 8 × 8 mm (Vivablock), composed of sequential single RCM images (500 × 500 μm). A standardized imaging procedure was performed in all cases. The Vivascope 1500 was centered on a representative lesion area on the glans and/or inner aspect of prepuce that was easily accessible to the adhesive tissue ring that couples the microscope to the skin. Depending on the location, the field of view varied from 4 to 7 mm2. These mosaics were composed for different skin levels, ranging from stratum corneum (if present), granular and spinous layer to the dermoepidermal junction (DEJ) and then upper and optionally deeper dermal layers. In addition, we provided VivaStacks from the center of the lesions: a series of 30 images—500 μm in diameter—in 5 μm steps to a depth of 150 μm. Comparable with routine histopathologic testing, the evaluation of RCM images was first performed at low magnification to examine the overall lesion architecture and then at higher magnification by zooming to get cytomorphologic details.

The presence or absence of characteristic RCM criteria was assessed by 3 independent observers (V.A.-S., P.K., and R.H.-W.) without further information on the lesions. A criterion was counted as positive if at least 2 observers found it.

HISTOPATHOLOGIC EVALUATION

The histologic sections were stained with hematoxylin-eosin and periodic acid–Schiff stains. The lesions were evaluated with regard to the presence or absence of established histopathologic criteria.46,13

In histopathologic evaluation, 6 cases were diagnosed as Zoon balanitis, 6 as nonspecific balanitis, and 3 as CIS.

EVALUATION OF CLINICAL IMAGES

The isolated clinical examination led to the diagnosis of 6 carcinomas (3 of them confirmed histologically) (Figure 2), 7 cases of balanitis, and 2 lesions of uncertain malignant potential (Figure 3).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Carcinoma in situ (CIS), erythroplasia of Queyrat. A, Clinical features: erosive, erythematous patches on the inner aspect of prepuce. B, Histopathologic features: atypical keratinocytes are present in all epidermal layers. The epidermis is acanthotic. Lymphocytes and extravasated erythrocytes are observed (hematoxylin-eosin, original magnification ×200). C, A reflectance confocal microscopic (RCM) image, epidermis, 1.5 × 1.5 mm: round nucleated cells, atypical honeycomb pattern (green circles), and disarranged epidermal pattern/focal loss (yellow circle). D, An RCM image, epidermis, 0.5 × 0.5 mm: round nucleated cells (yellow arrows), round papillary vessel (red arrow). E, An RCM image of the dermoepidermal junction, 1.5 × 1.5 mm: round papillary vessels (red arrows).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Zoon balanitis. A, Clinical features: atrophic to erosive red patches on the inner aspect of the prepuce, corresponding erythematous macula on the glans. B, Histopathologic features: the epidermis is atrophic. In the papillary dermis a bandlike infiltrate of predominantly plasma cells and dilated vessels is present (hematoxylin-eosin, original magnification ×40). C, A reflectance confocal microscopic (RCM) image, epidermis: 1 × 1 mm: nucleated honeycomb pattern. D, An RCM image, dermoepidermal junction, 1 × 1 mm: vermicular vessels (green arrows), round papillary vessels (pink arrows) and scattered small bright cells (white arrow). (Also see the .)

EVALUATION OF RCM IMAGES

The following criteria were used for evaluating the RCM images (Table 2).

Table Graphic Jump LocationTable 2. Name and Definition of the Evaluated Reflectance Confocal Microscopy Features, Frequency in This Study

Typical,14 atypical,15 and nucleated honeycomb pattern and disarranged epidermal pattern or focal loss15 are architectural features of the epidermis. The cytomorphologic features included round nucleated, dendritic, and scattered small bright cells16; the latter also were observed in dermal layers. The dermis was evaluated for 2 types of blood vessels. One type of vessel runs parallel to the surface and appears vermicular, the other runs perpendicular to the horizontal confocal imaging, producing a round appearance.15

All 3 cases of CIS were diagnosed correctly by RCM. The CIS showed an atypical honeycomb pattern as well as disarranged epidermal pattern/focal loss in all cases; nucleated and typical honeycomb pattern were not observed. In addition, round nucleated cells were present in 2 cases of CIS, and 2 cases showed scattered small bright cells in epidermis and dermis; dendritic cells were absent. Vermicular vessels were observed in 1 case only, whereas all CIS showed round papillary vessels.

The main architectural feature of the epidermis in balanitis was nucleated honeycomb pattern, which was observed in 11 of 12 cases; in addition, 6 cases showed typical honeycomb pattern. Atypical honeycomb pattern was viewed in 1 case and disarranged epidermal pattern in 3. In contrast to CIS, dendritic cells were verified in 6 cases of balanitis. All balanitis showed scattered small bright cells in the upper dermis, 11 cases in the epidermis. Vermicular vessels and round papillary vessels were found in all cases of balanitis.

The uninvolved skin (Figure 4) showed a typical honeycomb pattern in all cases (n = 5). A partially nucleated honeycomb pattern was present in 3 cases, whereas an atypical honeycomb pattern and disarranged epidermal pattern/focal loss were not observed. Dendritic cells (in 1 case), scattered small bright cells (in 3 cases) and vermicular vessels (in 1 case) were observed. Round papillary vessels were detected in all cases and round nucleated cells in none.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 4. Normal skin of the glans penis, reflectance confocal microscopic image, epidermis: 1.5 × 1.5 mm: nucleated honeycomb pattern on the top, typical honeycomb pattern on the bottom. Note the sharp demarcation between these 2 patterns.

Reflectance confocal microscopy imaging of the skin has been shown to be a useful tool for the evaluation of skin diseases (eg, neoplasms).1428 In general, genital skin is suitable for confocal microscopy because of its thin or absent cornified layer. In most of our cases, we observed a thin epidermis and flattened DEJ. These are optimized conditions for good image quality even in deeper dermal layers. A limiting factor of RCM on genital skin area is that, depending on the location, some lesions cannot be imaged with Vivascope 1500 because of difficulties in fixing the tissue ring on the lesion. The handheld Vivascope 3000 could compensate for this disadvantage in some cases because of its size, handling, and duration of imaging.

One drawback of this study is the small diagnostic spectrum of lesions in the enrolled patients; common diseases like psoriasis, lichen sclerosus et atrophicus, and infectious diseases are missing. Our intention, however, was to differentiate between balanitis and CIS.

Atypical honeycomb pattern, disarranged epidermal pattern, round papillary vessels, and round nucleated cells have been described as a common pattern in squamous cell carcinoma.14 In our study, all these findings were observed in CIS. Round nucleated cells, representing the atypical and dyskeratotic cells in histopathologic findings, were present in 2 of the 3 cases of CIS. Round papillary vessels are not helpful because they were present in all lesions and even in normal skin.

A second type of vessels with a distinct morphologic characteristic was detected ( ). Because of the flattened DEJ, an increased number of vessels running parallel to the surface with a tortuous, vermicular appearance was observed. This special kind of blood vessels was present in all cases of balanitis. We also observed this feature in normal skin at the periphery of carcinomas but never inside the lesions. We interpreted this as peritumoral inflammation. Nucleated honeycomb pattern is a kind of regular honeycomb pattern with small, bright, reflecting intercellular connections of cells containing bright, reflecting nuclei. A nucleated honeycomb pattern was observed in 11 of 12 cases of balanitis but not in carcinomas. Furthermore, we analyzed the presence of dendritic and scattered small bright cells. Dendritic cells showed a regular distribution in balanitis; the observers did not find it in carcinomas. We found no histopathologic equivalent for this morphologic finding. Just like round papillary vessels, scattered small bright cells were numerous and regularly distributed in both balanitis and CIS; therefore, they too are not useful for differentiating between inflammatory and malignant lesions on genital skin.

In addition, in 5 cases of balanitis we evaluated normal skin that was sharply demarcated from the area of balanitis. The most noticeable difference in comparison of balanitis and CIS was the presence of typical honeycomb pattern in all cases. Whether the nucleated honeycomb pattern in 3 cases was caused by the nearby inflammation could not be determined. All other features showed a nonspecific distribution. In summary, these observations give an idea how normal genital skin site may appear in RCM.

In conclusion, we have shown some new aspects of the use of RCM on genital skin, as well as confirming previous findings. It is advantageous that uncomfortable and painful biopsies from the genital area may be avoided in some cases. At the moment, the applicability of this method in routine practice is restricted not only by the need for confirmatory studies but also because the Vivascope 1500 is available only at a few specialized centers.

In general, genital skin is suitable for RCM imaging because of its morphologic attributes. Previously described criteria for squamous cell carcinomas, such as atypical honeycomb pattern, disarranged epidermal pattern/focal loss, and round nucleated cells, were observed also in the carcinomas of the glans and prepuce. A nucleated honeycomb pattern is associated with inflamed genital skin. Vermicular vessels were an impressive new feature ( ), correlating with inflammation and flattened DEJ. The concomitant presence of a nucleated honeycomb pattern and vermicular vessels and the absence of an atypical honeycomb pattern, disarranged epidermal pattern, and round nucleated cells is a clue for a benign inflammatory genital skin disease, whereas the presence of atypical honeycomb pattern, disarranged epidermal pattern and round, nucleated cells is a hint for malignant disease.

Correspondence: Peter Komericki, MD, Department of Environmental Dermatology and Venereology, Medical University of Graz, Auenbruggerplatz 1, Graz, Austria (peter.komericki@medunigraz.at).

Accepted for Publication: October 23, 2012.

Published Online: January 16, 2013. doi:10.1001/jamadermatol.2013.2440

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Arzberger and Komericki. Acquisition of data: Arzberger, Komericki, Massone, Chubisov, and Hofmann-Wellenhof. Analysis and interpretation of data: Arzberger, Komericki, Ahlgrimm-Siess, and Massone. Drafting of the manuscript: Arzberger, Komericki, Ahlgrimm-Siess, and Hofmann-Wellenhof. Critical revision of the manuscript for important intellectual content: Komericki and Chubisov. Administrative, technical, and material support: Arzberger and Ahlgrimm-Siess. Study supervision: Komericki and Massone.

Conflict of Interest Disclosures: None reported.

Online-Only Material: The video is available .

Zoon JJ, Zoon JJ. Chronic benign circumscript plasmocytic balanoposthitis.  Dermatologica. 1952;105(1):1-7
PubMed   |  Link to Article
Nödl F. Zur Klinik und Histologie der Balanoposthitis chronica circumscripta benigna plasmacellularis Zoon.  Arch Derm Syphilol. 1954;198(6):557-566
Souteyrand P, Wong E, MacDonald DM. Zoon's balanitis (balanitis circumscripta plasmacellularis).  Br J Dermatol. 1981;105(2):195-199
PubMed   |  Link to Article
Nikolowski W, Wiehl R. Pareiitis und Balanitis plasmacellularis.  Arch Klin Exp Dermatol. 1956;202(4):347-357
PubMed
Garnier G. Benign plasma-cell erythroplasia.  Br J Dermatol. 1957;69(3):77-81
PubMed   |  Link to Article
Leonforte JF. Balanitis circumscripta plasmacellularis: case report with ultrastructural study.  Acta Derm Venereol. 1982;62(4):352-356
PubMed
Joshi UY. Carcinoma of the penis preceded by Zoon's balanitis.  Int J STD AIDS. 1999;10(12):823-825
PubMed   |  Link to Article
Porter WM, Hawkins DA, Dinneen M, Bunker CB. Zoon's balanitis and carcinoma of the penis.  Int J STD AIDS. 2000;11(7):484-485
PubMed
Starritt E, Lee S. Erythroplasia of Queyrat of the glans penis on a background of Zoon's plasma cell balanitis.  Australas J Dermatol. 2008;49(2):103-105
PubMed   |  Link to Article
Balato N, Scalvenzi M, La Bella S, Di Costanzo L. Zoon's balanitis: benign or premalignant lesion?  Case Rep Dermatol. 2009;1(1):7-10
PubMed   |  Link to Article
Rajadhyaksha M, González S, Zavislan JM, Anderson RR, Webb RH. In vivo confocal scanning laser microscopy of human skin, II: advances in instrumentation and comparison with histology.  J Invest Dermatol. 1999;113(3):293-303
PubMed   |  Link to Article
Rajadhyaksha M, Grossman M, Esterowitz D, Webb RH, Anderson RR. In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast.  J Invest Dermatol. 1995;104(6):946-952
PubMed   |  Link to Article
Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of Zoon: a clinicopathologic study of 45 cases.  Am J Dermatopathol. 2002;24(6):459-467
PubMed   |  Link to Article
Scope A, Benvenuto-Andrade C, Agero AL,  et al.  In vivo reflectance confocal microscopy imaging of melanocytic skin lesions: consensus terminology glossary and illustrative images.  J Am Acad Dermatol. 2007;57(4):644-658
PubMed   |  Link to Article
Rishpon A, Kim N, Scope A,  et al.  Reflectance confocal microscopy criteria for squamous cell carcinomas and actinic keratoses.  Arch Dermatol. 2009;145(7):766-772
PubMed   |  Link to Article
Ardigò M, Maliszewski I, Cota C,  et al.  Preliminary evaluation of in vivo reflectance confocal microscopy features of discoid lupus erythematosus.  Br J Dermatol. 2007;156(6):1196-1203
PubMed   |  Link to Article
Horn M, Gerger A, Ahlgrimm-Siess V,  et al.  Discrimination of actinic keratoses from normal skin with reflectance mode confocal microscopy.  Dermatol Surg. 2008;34(5):620-625
PubMed   |  Link to Article
Ahlgrimm-Siess V, Cao T, Oliviero M, Hofmann-Wellenhof R, Rabinovitz HS, Scope A. The vasculature of nonmelanocytic skin tumors on reflectance confocal microscopy: vascular features of squamous cell carcinoma in situ.  Arch Dermatol. 2011;147(2):264
PubMed   |  Link to Article
Gerger A, Hofmann-Wellenhof R, Langsenlehner U,  et al.  In vivo confocal laser scanning microscopy of melanocytic skin tumours: diagnostic applicability using unselected tumour images.  Br J Dermatol. 2008;158(2):329-333
PubMed   |  Link to Article
Nori S, Rius-Díaz F, Cuevas J,  et al.  Sensitivity and specificity of reflectance-mode confocal microscopy for in vivo diagnosis of basal cell carcinoma: a multicenter study.  J Am Acad Dermatol. 2004;51(6):923-930
PubMed   |  Link to Article
Pellacani G, Guitera P, Longo C, Avramidis M, Seidenari S, Menzies S. The impact of in vivo reflectance confocal microscopy for the diagnostic accuracy of melanoma and equivocal melanocytic lesions.  J Invest Dermatol. 2007;127(12):2759-2765
PubMed
Pellacani G, Cesinaro AM, Seidenari S. Reflectance-mode confocal microscopy of pigmented skin lesions: improvement in melanoma diagnostic specificity.  J Am Acad Dermatol. 2005;53(6):979-985
PubMed   |  Link to Article
Ahlgrimm-Siess V, Massone C, Scope A,  et al.  Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: a preliminary study.  Br J Dermatol. 2009;161(6):1307-1316
PubMed   |  Link to Article
Gonzalez S, Gill M, Halpern AC. Reflectance Confocal Microscopy of Cutaneous Tumors: An Atlas With Clinical, Dermoscopic and Histological Correlations. New York, NY: Informa HealthCare; 2008:30-75
Aghassi D, Anderson RR, González S. Confocal laser microscopic imaging of actinic keratoses in vivo: a preliminary report.  J Am Acad Dermatol. 2000;43(1, pt 1):42-48
PubMed   |  Link to Article
Ulrich M, Maltusch A, Rius-Diaz F,  et al.  Clinical applicability of in vivo reflectance confocal microscopy for the diagnosis of actinic keratoses.  Dermatol Surg. 2008;34(5):610-619
PubMed   |  Link to Article
Ulrich M, Forschner T, Röwert-Huber J,  et al.  Differentiation between actinic keratoses and disseminated superficial actinic porokeratoses with reflectance confocal microscopy.  Br J Dermatol. 2007;156:(suppl 3)  47-52
PubMed   |  Link to Article
Ahlgrimm-Siess V, Hofmann-Wellenhof R, Cao T, Oliviero M, Scope A, Rabinovitz HS. Reflectance confocal microscopy in the daily practice.  Semin Cutan Med Surg. 2009;28(3):180-189
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. CONSORT diagram. RCM indicates reflectance confocal microscopy.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Carcinoma in situ (CIS), erythroplasia of Queyrat. A, Clinical features: erosive, erythematous patches on the inner aspect of prepuce. B, Histopathologic features: atypical keratinocytes are present in all epidermal layers. The epidermis is acanthotic. Lymphocytes and extravasated erythrocytes are observed (hematoxylin-eosin, original magnification ×200). C, A reflectance confocal microscopic (RCM) image, epidermis, 1.5 × 1.5 mm: round nucleated cells, atypical honeycomb pattern (green circles), and disarranged epidermal pattern/focal loss (yellow circle). D, An RCM image, epidermis, 0.5 × 0.5 mm: round nucleated cells (yellow arrows), round papillary vessel (red arrow). E, An RCM image of the dermoepidermal junction, 1.5 × 1.5 mm: round papillary vessels (red arrows).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Zoon balanitis. A, Clinical features: atrophic to erosive red patches on the inner aspect of the prepuce, corresponding erythematous macula on the glans. B, Histopathologic features: the epidermis is atrophic. In the papillary dermis a bandlike infiltrate of predominantly plasma cells and dilated vessels is present (hematoxylin-eosin, original magnification ×40). C, A reflectance confocal microscopic (RCM) image, epidermis: 1 × 1 mm: nucleated honeycomb pattern. D, An RCM image, dermoepidermal junction, 1 × 1 mm: vermicular vessels (green arrows), round papillary vessels (pink arrows) and scattered small bright cells (white arrow). (Also see the .)

Place holder to copy figure label and caption
Graphic Jump Location

Figure 4. Normal skin of the glans penis, reflectance confocal microscopic image, epidermis: 1.5 × 1.5 mm: nucleated honeycomb pattern on the top, typical honeycomb pattern on the bottom. Note the sharp demarcation between these 2 patterns.

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics, Clinical, Histopathologic, and Reflectance Confocal Microscopy Diagnoses
Table Graphic Jump LocationTable 2. Name and Definition of the Evaluated Reflectance Confocal Microscopy Features, Frequency in This Study

References

Zoon JJ, Zoon JJ. Chronic benign circumscript plasmocytic balanoposthitis.  Dermatologica. 1952;105(1):1-7
PubMed   |  Link to Article
Nödl F. Zur Klinik und Histologie der Balanoposthitis chronica circumscripta benigna plasmacellularis Zoon.  Arch Derm Syphilol. 1954;198(6):557-566
Souteyrand P, Wong E, MacDonald DM. Zoon's balanitis (balanitis circumscripta plasmacellularis).  Br J Dermatol. 1981;105(2):195-199
PubMed   |  Link to Article
Nikolowski W, Wiehl R. Pareiitis und Balanitis plasmacellularis.  Arch Klin Exp Dermatol. 1956;202(4):347-357
PubMed
Garnier G. Benign plasma-cell erythroplasia.  Br J Dermatol. 1957;69(3):77-81
PubMed   |  Link to Article
Leonforte JF. Balanitis circumscripta plasmacellularis: case report with ultrastructural study.  Acta Derm Venereol. 1982;62(4):352-356
PubMed
Joshi UY. Carcinoma of the penis preceded by Zoon's balanitis.  Int J STD AIDS. 1999;10(12):823-825
PubMed   |  Link to Article
Porter WM, Hawkins DA, Dinneen M, Bunker CB. Zoon's balanitis and carcinoma of the penis.  Int J STD AIDS. 2000;11(7):484-485
PubMed
Starritt E, Lee S. Erythroplasia of Queyrat of the glans penis on a background of Zoon's plasma cell balanitis.  Australas J Dermatol. 2008;49(2):103-105
PubMed   |  Link to Article
Balato N, Scalvenzi M, La Bella S, Di Costanzo L. Zoon's balanitis: benign or premalignant lesion?  Case Rep Dermatol. 2009;1(1):7-10
PubMed   |  Link to Article
Rajadhyaksha M, González S, Zavislan JM, Anderson RR, Webb RH. In vivo confocal scanning laser microscopy of human skin, II: advances in instrumentation and comparison with histology.  J Invest Dermatol. 1999;113(3):293-303
PubMed   |  Link to Article
Rajadhyaksha M, Grossman M, Esterowitz D, Webb RH, Anderson RR. In vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast.  J Invest Dermatol. 1995;104(6):946-952
PubMed   |  Link to Article
Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of Zoon: a clinicopathologic study of 45 cases.  Am J Dermatopathol. 2002;24(6):459-467
PubMed   |  Link to Article
Scope A, Benvenuto-Andrade C, Agero AL,  et al.  In vivo reflectance confocal microscopy imaging of melanocytic skin lesions: consensus terminology glossary and illustrative images.  J Am Acad Dermatol. 2007;57(4):644-658
PubMed   |  Link to Article
Rishpon A, Kim N, Scope A,  et al.  Reflectance confocal microscopy criteria for squamous cell carcinomas and actinic keratoses.  Arch Dermatol. 2009;145(7):766-772
PubMed   |  Link to Article
Ardigò M, Maliszewski I, Cota C,  et al.  Preliminary evaluation of in vivo reflectance confocal microscopy features of discoid lupus erythematosus.  Br J Dermatol. 2007;156(6):1196-1203
PubMed   |  Link to Article
Horn M, Gerger A, Ahlgrimm-Siess V,  et al.  Discrimination of actinic keratoses from normal skin with reflectance mode confocal microscopy.  Dermatol Surg. 2008;34(5):620-625
PubMed   |  Link to Article
Ahlgrimm-Siess V, Cao T, Oliviero M, Hofmann-Wellenhof R, Rabinovitz HS, Scope A. The vasculature of nonmelanocytic skin tumors on reflectance confocal microscopy: vascular features of squamous cell carcinoma in situ.  Arch Dermatol. 2011;147(2):264
PubMed   |  Link to Article
Gerger A, Hofmann-Wellenhof R, Langsenlehner U,  et al.  In vivo confocal laser scanning microscopy of melanocytic skin tumours: diagnostic applicability using unselected tumour images.  Br J Dermatol. 2008;158(2):329-333
PubMed   |  Link to Article
Nori S, Rius-Díaz F, Cuevas J,  et al.  Sensitivity and specificity of reflectance-mode confocal microscopy for in vivo diagnosis of basal cell carcinoma: a multicenter study.  J Am Acad Dermatol. 2004;51(6):923-930
PubMed   |  Link to Article
Pellacani G, Guitera P, Longo C, Avramidis M, Seidenari S, Menzies S. The impact of in vivo reflectance confocal microscopy for the diagnostic accuracy of melanoma and equivocal melanocytic lesions.  J Invest Dermatol. 2007;127(12):2759-2765
PubMed
Pellacani G, Cesinaro AM, Seidenari S. Reflectance-mode confocal microscopy of pigmented skin lesions: improvement in melanoma diagnostic specificity.  J Am Acad Dermatol. 2005;53(6):979-985
PubMed   |  Link to Article
Ahlgrimm-Siess V, Massone C, Scope A,  et al.  Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: a preliminary study.  Br J Dermatol. 2009;161(6):1307-1316
PubMed   |  Link to Article
Gonzalez S, Gill M, Halpern AC. Reflectance Confocal Microscopy of Cutaneous Tumors: An Atlas With Clinical, Dermoscopic and Histological Correlations. New York, NY: Informa HealthCare; 2008:30-75
Aghassi D, Anderson RR, González S. Confocal laser microscopic imaging of actinic keratoses in vivo: a preliminary report.  J Am Acad Dermatol. 2000;43(1, pt 1):42-48
PubMed   |  Link to Article
Ulrich M, Maltusch A, Rius-Diaz F,  et al.  Clinical applicability of in vivo reflectance confocal microscopy for the diagnosis of actinic keratoses.  Dermatol Surg. 2008;34(5):610-619
PubMed   |  Link to Article
Ulrich M, Forschner T, Röwert-Huber J,  et al.  Differentiation between actinic keratoses and disseminated superficial actinic porokeratoses with reflectance confocal microscopy.  Br J Dermatol. 2007;156:(suppl 3)  47-52
PubMed   |  Link to Article
Ahlgrimm-Siess V, Hofmann-Wellenhof R, Cao T, Oliviero M, Scope A, Rabinovitz HS. Reflectance confocal microscopy in the daily practice.  Semin Cutan Med Surg. 2009;28(3):180-189
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Multimedia Related by Topic
Articles Related By Topic
Related Topics
PubMed Articles