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Balanoposthitis

The right clinical information, right where it's needed

Last updated: Apr 15, 2015


Table of Contents
Summary 3

Basics 4

Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 6
Classification 6

Prevention 8

Primary prevention 8
Screening 8
Secondary prevention 8

Diagnosis 9

Case history 9
Step-by-step diagnostic approach 9
Risk factors 11
History & examination factors 12
Diagnostic tests 13
Differential diagnosis 14

Treatment 19

Step-by-step treatment approach 19


Treatment details overview 21
Treatment options 23

Follow up 37

Recommendations 37
Complications 37
Prognosis 37

Guidelines 38

Diagnostic guidelines 38
Treatment guidelines 38

References 40

Disclaimer 43
Summary

◊ Balanoposthitis refers to inflammation of the glans penis and prepuce. It is a descriptive term and not a diagnosis.

◊ There are numerous causes; these can be broadly divided into inflammatory, infective, and pre-cancerous.

◊ The aim of diagnosis and management should be to exclude STD, minimise problems with sexual and urinary
function, and reduce the risk of cancer of the penis.

◊ A specific causative condition should be identified and treated aggressively. Non-specific balanoposthitis is a
diagnosis of exclusion.

◊ Patients will typically present in a primary care setting. Input from specialists, particularly dermatologists and
urologists, may be very helpful in the management of poorly responsive or complex cases.
Balanoposthitis Basics

Definition

Balanoposthitis refers to inflammation of the glans penis and prepuce. It is a descriptive term rather than a diagnosis. It
BASICS

can be regarded as a special sort of dermatosis that occurs within a skin fold (i.e., an intertrigo). By definition, balanoposthitis
cannot occur in a circumcised male, although balanitis (inflammation of the glans penis) might. There are many possible
causes of balanoposthitis, and these can be broadly divided into inflammatory, infectious, and pre-cancerous.[1]

Epidemiology

The incidence and prevalence of balanoposthitis are not known with accuracy as it is a descriptive term rather than a
diagnosis. Patients with balanoposthitis tend to present initially to their general practitioners. They may then be referred
to dermatology, GU medicine, or urology for further examination and investigation. Generally, dermatologists feel that
balanitis, posthitis, and balanoposthitis are most commonly due to inflammatory dermatoses (e.g., lichen sclerosus,
eczema, psoriasis, lichen planus, Zoon balanitis) or pre-cancerous conditions (e.g., erythroplasia of Queyrat). GU physicians
search for an infective cause (e.g., Candida, Group B beta-haemolytic streptococcus).[3] [4]

Aetiology

The aetiology of balanoposthitis depends on the underlying condition. The genitalia may be a site of predilection for
inflammatory dermatoses in part due to the Koebner phenomenon (the tendency for skin disorders to appear at sites of
trauma). Exposure to potential irritants (e.g., urine, soap), allergens, or infective agents may predispose the delicate tissue
of the foreskin to become dysfunctional.

Common causes of balanoposthitis include:

• Atopic eczema/dermatitis: a common dermatosis associated with a personal and familial predisposition to dry skin
and other atopic diseases such as hay fever and asthma. Atopic eczema in isolation, however, is a rare cause of
balanoposthitis. It is not known how anogenital atopic eczema is related to circumcision, sexual activity and STD.

• Allergic contact eczema: caused by a type IV allergic reaction involving cell-mediated immunity after prior
sensitisation to the agent concerned. A number of common allergens (e.g., lanolin, fragrance, nickel, rubber) cause
a significant proportion of reactions. The risks to the anogenital area (and occasionally the resultant balanoposthitis)
result from 3 possible factors:

• 1. Direct contact with the allergen[5] [6] [7]

• 2. Transfer of the allergen from another part of the anatomy

• 3. Involvement in a more generalised eczematous response (e.g., to a medicine or dressing used on venous
eczema or ulceration, as in the auto-sensitisation/secondary spread/secondary generalisation syndrome).

• Irritant contact eczema: occurs from direct toxicity and can occur in patients without prior sensitisation. The prepuce
and glans penis may be considered as vulnerable sites. Irritation may be due to friction from adjacent skin and
clothing, toilet paper and towels, sweat, sebum, desquamated corneocytes, dirt, excreta, sexual secretions,
detergents, toiletries and cosmetics, contraceptives, some topical treatments, or systemic medicine secreted in

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Balanoposthitis Basics

the urine (e.g., foscarnet).[8] [9] Excessive washing with soap and toiletries is another important factor, and there
may be an association with atopy.[10]

• Seborrhoeic dermatitis: a very common pattern of eczematous or psoriasiform inflammation that probably results

BASICS
from a diathesis that confers an abnormal hypersensitivity to the normal commensal cutaneous yeast Pityrosporum
ovale.

• Psoriasis: a common anogenital diagnosis in isolation or supported by other clinical signs. The cause of psoriasis
is unknown. Psoriasis is regarded as a disorder of primary immuno-dysregulation determined both by a genetic
predisposition and environmental triggers (perhaps streptococcal or other super-antigens) that results in the
pathological hallmarks of the disease-vascular changes, leukocyte infiltration, and epidermal hyper-proliferation.

• Reiter's disease: part of the same continuum as psoriasis in genetically predisposed people. Reiter's syndrome is
defined as arthritis, urethritis, and conjunctivitis.[11] It is precipitated by non-gonococcal urethritis or bacillary or
amoebic dysentery and associated with HLA-B27.

• Lichen sclerosus: a chronic, inflammatory, and scarring dermatosis with a predilection for the genitalia and a
low-grade risk of squamous cell carcinoma.[12] [13] [14] Genital disease affects only the uncircumcised male.[15]
Lichen sclerosus of the penis may be asymptomatic, but diverse and vague symptomatology is often encountered[16]
[17] [18] [19] [20] [21] Anti-ECM1 (extracellular matrix protein 1) autoantibodies detected in patients with lichen
sclerosus may be an epiphenomenon, rather than the causative mechanism.[22] Although urine is postulated to
play a role in the pathogenesis of lichen sclerosus, no anomalous spectral profile of urine constituents was identified
by nuclear magnetic resonance spectroscopy of urine in men with lichen sclerosus. It is beyond doubt that the
irritant effect of urine may play a role.[23] [24] Gene expression profiling has been done in penile lichen sclerosus
and shows a non-specific inflammatory tissue response and supports the hypothesis that lichen sclerosus is a
chronic non-specific inflammatory disease.[25]

• Zoon balanitis: a disorder of middle-aged and older uncircumcised men with uncertain aetiology.[26] [27] The
evidence suggests that Zoon balanitis is a chronic, reactive, principally irritant mucositis related to a dysfunctional
prepuce.[28] [29] Chronic infection with Mycobacterium smegmatis has been postulated and HPV infection has
been implicated.[30] [31] Trauma and irritation by urine are probably important factors.[30]

• Non-specific balanoposthitis: a diagnosis of exclusion and probably not common. Candidosis may be present as a
secondary opportunistic phenomenon, rather than as a primary cause of disease, in most if not all cases. Preputial
dysfunction is the likely cause and many cases probably have lichen sclerosus as the underlying condition.

• Candidosis: GU physicians believe that Candida can be the cause of urethritis and balanoposthitis.[32] [33] Candida
may also be a secondary pathogen in anogenital dermatoses. Candidal balanoposthitis could be an STD with an
affinity for the anatomically abnormal penis or in people predisposed by underlying disease or other factors.

• Gonorrhoea: this STD usually presents around 4 to 7 days after infection as urethritis (with purulent semen-like
discharge) or more rarely as pharyngitis or conjunctivitis. Anogenital skin manifestations commonly include
balanoposthitis and meatal, preputial, and penile oedema and, less commonly, painful lymphadenopathy.

• Carcinoma in situ of the penis: (may be referred to as erythroplasia of Queyrat when it occurs on the glans, and
Bowen's disease when it occurs on the penile shaft); underlying cause principally related to HPV infection and
lichens sclerosus.

Rare causes of balanoposthitis include:

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Balanoposthitis Basics

• Dermatological bacterial infections (e.g., streptococcal dermatitis, staphylococcal cellulitis, mycoplasma)

• Dermatological fungal infections (e.g., tinea)


BASICS

• Dermatological parasitic infections (e.g., myiasis, scabies, amoebiasis)

• Sexually transmitted infections (e.g., syphilis, trichomonas vaginalis, lymphogranuloma venereum, non-syphilitic
spirochetal ulcerative balanoposthitis)

• Auto-immune diseases (e.g., inflammatory vitiligo, Crohn's disease)

• Neoplastic conditions (e.g., Kaposi's sarcoma, chronic lymphatic leukaemia)

• Drug related (e.g., fixed drug eruption)

• Other conditions (e.g., lichen planus, eccrine syringofibroadenomatosis).

Pathophysiology

The foreskin is a delicate tissue in contact with sweat, moisture, heat, urine, sexual secretions, desquamative products,
detergents, potential allergens, and infectious agents. Any of these factors can lead to genital irritation, pain, and
dysfunction (e.g., paraphimosis/phimosis, dribbling of urine, dyspareunia). Further progression of infection or inflammation
can cause scarring, disfigurement, and, rarely, pre-cancerous or cancerous lesions.

Classification

Conditions affecting the glans and prepuce[2]


Infectious

• Candida albicans

• Streptococci

• Anaerobes

• Staphylococci

• Trichomonas vaginalis

• Herpes simplex virus

• Human papillomavirus

• Mycoplasma genitalium

Inflammatory dermatosis

• Lichen sclerosus

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Balanoposthitis Basics

• Lichen planus

• Psoriasis and circinate balanitis

BASICS
• Zoon’s balanitis

• Eczema (including irritant, allergic, and seborrhoeic)

• Allergic reactions (including fixed drug eruption and Stevens-Johnson syndrome)

Pre-malignant (penile carcinoma in situ)

• Bowen’s disease

• Bowenoid papulosis

• Erythroplasia of Queyrat

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Balanoposthitis Prevention

Primary prevention
Primary preventative measures are not generally considered necessary. However, circumcision protects men from many
of these conditions, as it is the presence of the foreskin that provides the predisposing conditions for balanoposthitis.[35]
[36]

Screening

Patients with balanoposthitis tend to present initially to their general practitioners. They may then be referred to
dermatology, GU medicine, or urology for further examination and investigation. All patients should be screened for
infections, inflammatory skin conditions, and pre-cancerous or cancerous lesions. A multi-disciplinary approach, with
different specialists providing consultation and treatment as indicated, can be very helpful.

Secondary prevention
PREVENTION

Patients should be advised to pay attention to personal hygiene. With regard to the genital area, they should be advised
to:

• Avoid irritants (e.g., soiling with urine, long pubic hair, antibacterial soaps) and over-washing (i.e., with vigorous use
of washcloths)

• Fully dry the head of the penis after washing (uncircumcised males)

• Avoid the use of common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners)

• Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum
jelly, aqueous creams, lotions) when needed

• Use a lubricant during sexual intercourse to ameliorate dyspareunia

• If at risk of carcinoma in situ or cancer of the penis (e.g., people with immunosuppression [HIV or iatrogenic]), then
adjuvant HPV vaccination can be considered.

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Balanoposthitis Diagnosis

Case history

Case history #1
A 55-year-old man presents with a 5-year history of itching and burning of the glans penis and 'tightness' of the
foreskin. He reports discomfort and occasional tearing of the foreskin during sexual intercourse. On examination, he
has symmetrical white atrophic patches with telangiectasia on the glans penis, meatal stenosis, and a tight, inflamed
foreskin. The cause of the balanoposthitis is lichen sclerosus.

Case history #2
A 60-year-old uncircumcised man presents with a 1-year history of a red rash on his glans penis and the overlying
foreskin. It is usually asymptomatic but occasionally sore. He is troubled by the appearance and worried he has picked
up an infection or a malignancy. STD screens were negative. Clinically, he had a bright red glassy appearance to his
glans penis and the overlying foreskin was similarly affected. This looked like Zoon balanitis and a skin biopsy was
taken to confirm the diagnosis.

Step-by-step diagnostic approach


Every attempt should be made to make a precise diagnosis when patients present with signs of balanoposthitis. Non-specific
balanoposthitis is a diagnosis of exclusion and probably not common. STDs, immunosuppression and diabetes must all
be excluded.

As with all dermatological and GU conditions, a full history should be taken and a thorough examination performed.
Investigations may include appropriate swabs and skin biopsy. Two major goals of diagnosis and management should
be to minimise problems with sexual and urinary function and identify any conditions placing the patient at risk of
developing cancer of the penis.

A primary dermatosis is often present, such as psoriasis, seborrhoeic dermatitis, Zoon balanitis, lichen sclerosus, lichen

DIAGNOSIS
planus, warts or carcinoma-in-situ. A suitably targeted biopsy can be helpful in the diagnosis, but histology may be
non-specific. Preputial dysfunction is probably the cause in cases of non-specific balanoposthitis, and many patients are
likely to have lichen sclerosus as the underlying morbid state.

Candidosis may be present as a secondary opportunistic phenomenon rather than as a primary cause of disease, in most
if not all cases. Candidal balanoposthitis could be an STD with an affinity for the anatomically abnormal penis or in people
predisposed by underlying disease or other factors. Screening should be done for other STDs.

History and symptoms


The history of the presenting complaint should include an enquiry into the nature of current symptoms. These will
often include:

• Pruritus (patients often complain of the cosmetic insult rather than of itch, which may be mild)

• Pain or soreness

• Dribbling (incontinence can cause skin irritation/dermatitis).

Factors in social and sexual history applicable to further evaluation include:

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Balanoposthitis Diagnosis

• Age of the patient. Younger men are more likely to suffer from an infectious cause of balanoposthitis, while
neoplasm may be a more likely cause in older men

• Relationship status. Single or married, or in a long-term relationship

• Sexual history. Number of partners, recent sexual activity, route of intercourse (vaginal, oral, anal) and sexual
orientation (heterosexual, homosexual, bi-sexual)

• Contraception. Regular and consistent condom use makes an STD less likely, but does not rule it out entirely.
In rare instances, allergy to latex or lubricants in condoms may be a contributing factor

Important factors in personal and family medical history include:

• Circumcision. Removal of the foreskin protects men from many of the causative conditions of balanoposthitis[35]
[36]

• Atopy (eczema, hay fever, asthma, type I allergies). Examine patient for evidence of atopic dermatitis elsewhere
on skin

• Psoriasis. Examine for evidence of psoriasis elsewhere on the skin (e.g., elbows, knees, scalp and lumbosacral
areas) and nails (nail pits and onycholysis)

• Urological history and symptomatology. Consider any history of genital warts, penile discharge or dysuria.

Drug history should attempt to determine allergies to any of the following:

• Systemic medicines. These can be associated with drug eruption, including fixed-drug eruption, which often is
localised to the genitalia

• Topical medicines. Can be associated with local irritant or allergic reactions at sites of application

• Non-prescription medicines.
DIAGNOSIS

Examination
The examination should not only include the genital region, but also the rest of the body. Special attention should be
given to inguinal folds and lymph nodes, scrotum and contents, perineum and anus. The mucous membranes, scalp
and hair, nails, teeth, ears, glabella and brows, nasolabial folds, axillae, chest and back all also require examination.

The prepuce should be examined for phimosis/paraphimosis and the presence/absence of rash and inflammatory
changes. Evaluation of a rash should consider distribution and morphology. Other possible findings include:

• Hypo-pigmentation (vitiligo)

• Post-inflammatory hypo-/hyper-pigmentation

• Purpura (lichen sclerosus)

• Red scaly patches (psoriasis, Reiter's, atopic dermatitis, allergic or irritant contact dermatitis)

• Red plaques (Zoon, erythroplasia of Queyrat, gonorrhoea)

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Balanoposthitis Diagnosis

• Erosions (herpes simplex, lichen sclerosus, candidosis, syphilis [chancre], squamous cell carcinoma)

• Blisters (allergic contact dermatitis)

• Papules/micro-papules (lichen planus)

• Pustules (candidosis).

Any lump should be assessed in terms of the site and morphology. Common causes of genital nodules include benign
cysts (e.g., median raphe cysts, epidermoid cysts), scabies (especially if pruritic nodules present on glans) and squamous
cell carcinoma (may have ulcerated surface).

Lesions of significance can display slight erythema, slight to moderate scaling, and often peri-follicular or frank follicular
involvement.

Investigations
These are performed as needed to identify specific causative factors. Investigations may include:

• Microbiology: Gram stain and culture for bacteria and Candida, including specific testing for gonorrhoea and
chlamydia if indicated

• Dark-field examination of serum from an ulcer: indicated in suspected cases of syphilis

• Virology: viral culture and/or examination for viral inclusions by either Tzanck preparation or direct fluorescent
antibody staining for herpes simplex virus; used to clarify diagnostic uncertainty

• Mycology: KOH preparation for Candida may be indicated if this agent/fungal infection is suspected or needs
to be excluded

• Skin biopsy: indicated to clarify diagnostic uncertainty. If balanoposthitis does not improve after implementation
of indicated therapy, consider skin biopsy to exclude pre-malignant (e.g., erythroplasia of Queyrat) and malignant
(e.g., squamous cell carcinoma) skin conditions[37]

DIAGNOSIS
• Patch testing: perform only if allergic contact dermatitis is suspected or needs to be excluded.

Risk factors
Strong
congenital or acquired dysfunctional foreskin
• Risk factor for lichen sclerosus, Zoon balanitis, and non-specific balanoposthitis.

uncircumcised state
• Risk factor for lichen sclerosus, Zoon balanitis, and non-specific balanoposthitis, especially if the foreskin is
dysfunctional.

poor hygiene; urinary dribbling or leakage


• Risk factor for Zoon balanitis.

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Balanoposthitis Diagnosis
over-washing
• Risk factor for irritant contact dermatitis.

human papilloma virus (HPV) infection


• Risk factor for non-specific balanoposthitis, and penile pre-cancers and cancers.
• This applies only to certain HPV types; clinically obvious genital warts caused by HPV types 6 and 11 have no
pre-cancer potential.

Weak
inflammatory skin diseases
• Such as eczema, seborrhoeic dermatitis, and psoriasis. Risk factor for genital skin involvement and balanoposthitis.

Borrelia infection
• Unlikely risk factor for lichen sclerosus (one study using focus-floating microscopy found evidence of Borrelia
infection in early lichen sclerosus).[34]

History & examination factors


Key diagnostic factors

presence of risk factors (common)


• Key risk factors include congenital or acquired dysfunctional foreskin, poor hygiene, over-washing, and HPV infection.

uncircumcised state (common)


• Circumcision is protective against penile cancer, UTIs, and STDs.

Other diagnostic factors


DIAGNOSIS

multiple sexual partners (common)


• Multiple sexual partners and/or high-risk sexual behaviours increases risk for acquisition of STDs

high-risk sexual behaviours (common)


• Multiple sexual partners and/or high-risk sexual behaviours increases risk for acquisition of STDs

post-inflammatory hypo- or hyper-pigmentation (common)


• May be seen following resolution of any inflammatory dermatosis (e.g., eczema, psoriasis, contact dermatitis).
Fixed-drug eruptions involving the genitalia often resolve with marked post-inflammatory hyper-pigmentation.

pruritus (common)
• Common complaint in cases of eczema, contact dermatitis, scabies.

red scaly patches (common)


• Present in inflammatory dermatoses such as eczema, seborrhoeic dermatitis, psoriasis, and Reiter's disease.

erosions (common)
• Seen in infections (herpes simplex, candidosis, syphilis), lichen sclerosus, squamous cell carcinoma.

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Balanoposthitis Diagnosis
personal/family history of atopy (eczema, hay fever, asthma, type I allergies) (uncommon)
• Patients with atopic background have increased likelihood of experiencing irritant and/or allergic contact dermatitis.
Atopic dermatitis uncommonly involves the genital area.

personal/family history of psoriasis (uncommon)


• There is a strong genetic predisposition to psoriasis. Genital involvement may be the only manifestation of psoriasis,
but examination of additional body sites often reveals other psoriatic lesions or signs (e.g., nail involvement).

urinary dribbling (uncommon)


• Urinary incontinence can result in skin irritation/breakdown. Chronic moisture can result in acquisition of candidosis.

hypo-pigmentation (uncommon)
• Markedly hypo-pigmented or de-pigmented patches on genitalia can be seen in vitiligo. Additional lesions of vitiligo
are often found on examination at other body sites (especially peri-orificial and acral areas).

purpura (uncommon)
• Common finding in lichen sclerosus; additional findings include skin atopy and hypo-pigmentation.

red plaques (uncommon)


• Present in Zoon balanitis, erythroplasia of Queyrat, gonorrhoea.

blisters (uncommon)
• Can be seen in cases of acute allergic or irritant contact dermatitis.

papules or micro-papules (uncommon)


• Seen in lichen planus (flat papules with slight scale). If this diagnosis is suspected, oral cavity and nails are examined
as well for findings of lichen planus.

pustules (uncommon)

DIAGNOSIS
• Can be seen with candidosis; diagnosis is confirmed with KOH preparation or culture.

Diagnostic tests
1st test to order

Test Result
swab for microbiology (Gram stain and culture) may be positive for bacterial
infection or Candida infection
• KOH preparation for Candida may be indicated if this agent/fungal infection
is suspected or needs to be excluded.
• Chocolate agar can be used to culture Neisseria gonorrhoeae.
• A non-culture technique such as nucleic acid amplification test (NAAT) is
currently recommended for Chlamydia.
swab/smear for virology positive Tzanck smear or direct
fluorescent staining in HSV
• Test involves viral culture and/or examination for viral inclusions by either
infection
Tzanck preparation or direct fluorescent antibody staining for HSV.

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Balanoposthitis Diagnosis

Test Result
dark-field microscopy may be positive for syphilis
• Not usually available outside specialist settings. A single negative result does bacteria
not exclude infection; ideally 3 negative examinations on different days are
required.

Other tests to consider

Test Result
skin biopsy findings reported by
histopathologist consistent
• It is important to ensure that the right specimen is obtained from the
appropriate site and to provide the pathologist with adequate information.[37] with causative condition
• For local anaesthesia, it is safe to use a small amount of adrenaline (epinephrine;
1:200,000), as the penis is a highly vascular organ. A small bleb can be created
by introducing a small quantity of anaesthetic (e.g., 2% xylocaine with adrenaline
1:200,000).
• A small incisional biopsy can be taken with a 3- or 4-mm punch biopsy. Avoid
biopsying the glans (unless there is not suitable lesion or rash elsewhere) and
near the frenulum where the urethra is very close to the surface. An absorbable
suture can be placed to close the wound.
patch testing may be positive in allergic
• Performed if allergic contact dermatitis is suspected or needs to be excluded. contact dermatitis
• Interpreted by a dermatologist in a patch test clinic setting.

Differential diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
DIAGNOSIS

Eczema and dermatitis • Characterised by erythematous • Diagnosis is clinical.


scaly plaques. Pruritus is often a
prominent sign.

Atopic dermatitis • Characterised by erythematous • Diagnosis is clinical.


scaly patches and lichenified • Biopsy usually not necessary but
plaques. Pruritus is a prominent may be warranted in atypical
finding. Additional areas of cases.
involvement include the hands, • A high serum IgE level
ankles/feet, and flexural areas. strengthens clinical suspicion of
the presence of the atopic
tendency.

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Balanoposthitis Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Seborrhoeic dermatitis • Lesions with slight erythema, • Diagnosis is clinical (and includes
slight to moderate scaling, and noting response to treatment).
often peri-follicular or frank • Biopsy usually not necessary but
follicular involvement. may be warranted in atypical
• Other commonly affected areas cases.
include scalp, ears, glabella and
brows, nasolabial folds, axillae,
chest, back, and groin. Slight
dandruff, mild scaling of the
eyebrows, or scaling lesions in the
axillae or on the chest may be
present.
• Patients typically complain of the
cosmetic insult rather than of itch,
which may be mild.

Irritant contact dermatitis • Characterised by erythematous, • Diagnosis is clinical based on


scaly patch or plaque history, examination, and trial of
corresponding to site of treatment (i.e., avoiding presumed
application of irritant. irritant).

Allergic contact dermatitis • Symptoms are pain, burning, or • Management relies on the
itching. identification of the potential
• Signs include erythema, swelling, allergen and likely source, and
vesiculation and exudation, or then avoidance. There may be
erythematous scaling and clues to the inciting factors at
lichenification, depending on presentation, but subsequent
severity. These appear about 1 patch testing to identify
week after first contact with allergen(s) is required.[38]
allergen, if previously
unsensitised, or within hours to 1
to 2 days if sensitised.
• This is a relatively uncommon

DIAGNOSIS
cause of balanoposthitis.

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Balanoposthitis Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Psoriasis • Genital psoriasis presents with • Diagnosis of psoriasis is usually
variably itchy, silvery-scaled clinical; sometimes a biopsy is
erythematous patches or plaques necessary, to exclude Zoon
in circumcised men. Scale is balanitis, lichen planus,
absent from lesions on the glans erythroplasia of Queyrat, or
penis or in the preputial sac of Kaposi's sarcoma in
uncircumcised men, because of uncircumcised patients with
the mucosal site. solitary mucosal lesions.
• Identifying other areas of
involvement can help with the
diagnosis of psoriasis. Commonly
involved areas include the scalp,
ears, umbilicus, sacrum, natal
cleft, and nails.
• Psoriatic balanoposthitis can be
part of the spectrum of
inverse-pattern psoriasis (with
inter-triginous and flexural site
disease involvement) and may be
associated with inter-triginous
disease of the axillae, natal cleft,
gluteal folds, and groin.
• Bowen disease and
extra-mammary Paget's disease
may be misdiagnosed as psoriasis
when there are single or several
foci on the penile shaft and/or in
the groin.

Reiter's disease • Skin lesions in Reiter's disease • Diagnosis is clinical.


may be similar to those of • Test for HLA-B27 is positive in
psoriasis. Patients may present approximately 75% of patients.
with features of both psoriasis and
DIAGNOSIS

Reiter's syndrome.
• Classically, Reiter's patients have
thickened yellow palms and soles
with a cobblestone appearance,
with or without pustular lesions
(keratoderma blenorrhagica); and
characteristic involvement of the
penis (circinate balanitis), which,
when severe, can result in
balanoposthitis.

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Balanoposthitis Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Lichen sclerosus • Men with genital lichen sclerosus • Most cases of lichen sclerosus can
may be asymptomatic. Atrophic be diagnosed clinically.
white patches (leukoderma) or • If there is clinical doubt, a biopsy
plaques are most commonly seen. should be done. A biopsy is
The lesions can also present as mandatory if a lesion or part of a
hyper-trophic or lilac-coloured, lesion is eroded or verrucous
slightly scaly lichenoid patches or (warty).
plaques with telangiectasia and
sparse purpura.
• Patients may report symptoms
signifying sexual dysfunction or
dyspareunia (itching, burning,
pain, bleeding, tearing, splitting,
haemorrhagic blisters), discomfort
with urination, and narrowing of
the urinary stream and/or
concerns about the changing
anatomy of their genitalia.[17]
[18] [19] [20] [21] [39]
• Other presentations include
non-retractile foreskin,
paraphimosis, and urinary
retention (even renal failure). The
signs may be subtle with meatal
narrowing and slight tightening of
the prepuce (with retraction still
possible) due to sclerotic plaques
and bands.
• Severe changes due to the lichen
sclerosus and associated
non-specific or Zoonoid
balanoposthitis include

DIAGNOSIS
constrictive posthitis, adhesions,
loss of anatomical definition, and
dissolution or effacement of the
normally sharply defined
architectural features (e.g.,
frenulum and the coronal sulcus).
Overt changes of Zoon balanitis
may be more florid than the
underlying lichen sclerosus.
• Other urological complications
include balanoposthitis,
adhesions, phimosis,
paraphimosis, posthitis, balanitis
xerotica, and cancer.
• Post-inflammatory
hyper-pigmentation is
occasionally seen.

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Balanoposthitis Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Zoon balanitis • Well-demarcated, glistening, • Screening for STDs is usually
moist, shiny, bright-red or brown mandatory in patients with penile
patches involving the glans and lesions presumed to represent
mucosal prepuce. The urethra Zoon balanitis.
(fossa navicularis) may also be • A properly targeted biopsy is
involved. The lesions may advised; the pathologist should
demonstrate dark red stippling be encouraged to look for
(cayenne pepper spots) and concomitant disease (e.g., lichen
purpura with haemosiderin sclerosus), especially in the
deposition. foreskin specimen following
• Atypical or unusual morphology circumcision.
should be viewed with suspicion
and biopsied.

Non-specific balanoposthitis • Non-specific balanoposthitis is a • Diagnosis of exclusion.


diagnosis of exclusion and
probably not common.
• Candidosis may be present as a
secondary opportunistic
phenomenon rather than as a
primary cause of disease in most,
if not all, cases.
• Preputial dysfunction is the
probable cause in all cases, and in
many cases lichen sclerosus will
eventually be found as the
underlying morbid state.

Gonorrhoea • Erythematous patches may be • Gonorrhoea is caused by Neisseria


well demarcated and look very gonorrhoeae. It is a
similar to Zoon balanitis. gram-negative, intra-cellular
• Meatal, preputial, and penile diplococcic organism, diagnosed
oedema and, less commonly, by a stained smear of urethral
DIAGNOSIS

painful lymphadenopathy may be swab. Its presence is confirmed


present. by culture or nucleic acid
amplification tests.

Candidosis • Burning and soreness are more • Diagnosis is clinical and supported
likely than itch. The glans may be by direct demonstration of the
eroded. Coalescent red patches budding forms of the yeast and
or plaques involve the folds, often pseudohyphae in a KOH
with superficial erosions. preparation with India ink.
Microbiological culture is
confirmatory.
• If candidosis is diagnosed, a
clinical search for an underlying
dermatological or medical cause
should follow, as signs due to
Candida may be more obvious
than those of the underlying
cause.

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Balanoposthitis Treatment

Step-by-step treatment approach


Treatment includes general measures and specific treatment of the underlying condition.

General measures
Patients should be advised to pay attention to personal hygiene. With regard to the genital area, they should be advised
to:

• Avoid irritants (e.g., antibacterial soaps) and over-washing (e.g., vigorous use of washcloths)

• Fully dry the head of the penis after washing (uncircumcised males)

• Avoid using common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners)

• Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g.,
petroleum jelly, aqueous creams, lotions) when needed

• Use a lubricant during sexual intercourse to improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear. Any underlying infections and conditions should be treated
promptly with appropriate measures.

Atopic eczema
Treatment of atopic eczema includes application of emollients and topical corticosteroids. Oral antihistamines are
useful for patients with significant pruritus.

Seborrhoeic dermatitis
Other than general measures, treatment may not be required. For patients with significant erythema/inflammation,
topical antifungals in conjunction with mild or moderately potent topical corticosteroids are the initial treatment.
Topical calcineurin inhibitors can be used as an alternative to topical corticosteroid treatment. Oral itraconazole or
fluconazole can be used in severe cases (e.g., those with concomitant seborrhoeic folliculitis or in HIV infection).

Irritant contact dermatitis


Irritants, especially soaps and fragrances, should be identified and avoided. Topical corticosteroids should be applied.
Oral antihistamines are useful for patients with significant pruritus.

Allergic contact dermatitis


Identified allergens should be avoided and topical corticosteroids applied. Oral antihistamines are useful for patients
with significant pruritus. Aluminium acetate soaks are a helpful treatment adjunct in cases of severe acute contact
dermatitis with exudate/weeping.

Psoriasis
TREATMENT

Treatment includes topical corticosteroids combined with emollients. Other treatments include topical vitamin D
analogues (e.g., calcipotriene) or topical calcineurin inhibitors. In very severe disease, systemic treatment with agents
such as UV light, acitretin, methotrexate, ciclosporin (cyclosporine), or biological agents (e.g., etanercept) may be
required, and would be prescribed under specialist guidance.

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Balanoposthitis Treatment
Reiter's disease
Treatment is similar to that used for psoriasis with topical corticosteroids or topical calcineurin inhibitor and supportive
measures being employed initially. In cases with concurrent HIV infection oral retinoids can be particularly useful.

Lichen sclerosus
Treatment is with a high-potency topical corticosteroid. Secondary candidal and bacterial infections should also be
treated. Surgical intervention (e.g., circumcision) may be necessary in the event of lack or response to medical
treatment.

Gonorrhoea
The Centers for Disease Control and Prevention (CDC) has updated its gonorrhoea treatment guidelines and no longer
recommends the routine use of cefixime as data suggest that its effectiveness may be declining. The CDC now
recommends that ceftriaxone be used as a first-line agent along with either azithromycin or doxycycline. Azithromycin
is preferred as it is given as a convenient oral single dose and has decreased incidence of gonorrhoea resistance
compared with doxycycline.[40]

If ceftriaxone is not readily available, cefixime plus azithromycin or doxycycline is recommended. If the patient has a
severe cephalosporin allergy, a single high dose of azithromycin is recommended. However, if an alternative regimen
is used, the CDC recommends a test of cure 1 week after treatment.[40]

Patients who have persistent symptoms after treatment should be retested by culture, and if these cultures are
positive for gonococcus, isolates should be submitted for resistance testing. Patients who experience treatment
failure after treatment with alternative regimens should be treated with ceftriaxone and high-dose azithromycin and
should receive infectious disease consultation. A test of cure should be repeated 1 week after re-treatment. Treatment
failures should be reported to the CDC through the local or state health department within 24 hours of diagnosis.[40]

Clinicians should ensure that the patient's sex partners from the preceding 60 days are evaluated promptly with
culture and treated as indicated. If a heterosexual partner of a patient cannot be linked to evaluation and treatment
in a timely fashion, then expedited partner therapy should be considered.[40]

Patients and partners should, ideally, be seen by a GU specialist for evaluation and exclusion of other STDs.

Candidosis
Any underlying disease (e.g., diabetes, HIV) should be treated. In cases with severe erythema/inflammation, topical
azole antifungal agents are often very usefully combined with hydrocortisone. An oral azole antifungal (e.g., fluconazole)
may be indicated if the patient has not responded to topical therapies or if there is severe/widespread involvement,
as may be seen in immunocompromised patients. The patient is advised to keep the area as cool and dry as possible
and to wear undergarments that allow air to circulate (e.g., boxer-type underpants, white cotton underwear). Partners
may need treatment as well.

Non-specific balanoposthitis
Treatment is often difficult, as the balanoposthitis often does not respond to general measures, topical corticosteroids,
TREATMENT

and topical and systemic antibiotics. Surgical intervention (e.g., circumcision) may be necessary in the event of lack
of response to medical treatment and is curative in most instances.

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Balanoposthitis Treatment
Zoon balanitis
Patients are prescribed an intermittent application of high-potency topical corticosteroid (e.g., clobetasol) with or
without antibiotics and antifungal agents. Surgical intervention (e.g., circumcision) may be necessary in the event of
lack of response to medical treatment and is usually curative.

Treatment details overview


Consult your local pharmaceutical database for comprehensive drug information including contraindications, drug
interactions, and alternative dosing. ( see Disclaimer )

Acute ( summary )
Patient group Tx line Treatment

atopic eczema 1st topical corticosteroid + supportive measures

with significant pruritus adjunct oral antihistamines

seborrhoeic dermatitis 1st supportive measures

with significant plus topical antifungal


erythema/inflammation

adjunct topical corticosteroids

adjunct topical calcineurin inhibitors

with concomitant seborrhoeic plus oral azole antifungal under specialist direction
folliculitis or HIV infection

irritant contact dermatitis 1st irritant avoidance + supportive measures + topical


corticosteroids

with significant pruritus adjunct oral antihistamines

allergic contact dermatitis 1st allergen avoidance + supportive measures + topical


corticosteroids

with significant pruritus adjunct oral antihistamines

severe with exudate/weeping adjunct wet soaks

psoriasis 1st topical corticosteroid or topical calcineurin


inhibitor or topical vitamin D analogue + supportive
measures

severe systemic disease plus specialist systemic treatment


TREATMENT

Reiter's disease 1st topical corticosteroid or topical calcineurin


inhibitor + supportive measures

with HIV infection plus oral retinoids under specialist direction

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Balanoposthitis Treatment

Acute ( summary )
lichen sclerosus 1st topical corticosteroid ± antibiotic/antifungal

2nd surgery-circumcision

gonorrhoea 1st antibiotics

plus supportive measures

candidosis 1st identify underlying disease + topical antifungal +


supportive measures

severe erythema/inflammation plus topical corticosteroids

resistant to topical therapies or plus oral antifungal


severe/widespread involvement

non-specific balanoposthitis 1st lower-potency topical corticosteroids

plus supportive measures

adjunct targeted antibiotics or antifungals to treat


identified pathogens

2nd high-potency topical corticosteroids

3rd surgery-circumcision

Zoon balanitis 1st high-potency topical corticosteroids

plus supportive measures

adjunct targeted antibiotics or antifungals to treat


identified pathogens

2nd surgery-circumcision
TREATMENT

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Balanoposthitis Treatment

Treatment options

Acute
Patient group Tx line Treatment
atopic eczema 1st topical corticosteroid + supportive measures
» The lowest-potency topical corticosteroid capable of
containing disease should be used. Hydrocortisone is
a low-potency option and is used for mild cases,
whereas triamcinolone is a moderate-potency option
used in moderate/severe cases.

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

with significant pruritus adjunct oral antihistamines


» Oral antihistamines are useful for patients with
significant pruritus. Hydroxyzine is commonly used,
but may cause sedation. Non-sedating options include
cetirizine, fexofenadine, and loratadine.

Primary options
TREATMENT

» hydroxyzine: 25 mg orally every 6-8 hours when


required, maximum 100 mg/day

OR
» cetirizine: 10 mg orally once daily

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
OR
» fexofenadine: 60 mg orally twice daily, or 180 mg
orally once daily

OR
» loratadine: 5-10 mg orally once daily

seborrhoeic dermatitis 1st supportive measures


» Patients should be advised to pay attention to
personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

with significant plus topical antifungal


erythema/inflammation » Topical antifungals (e.g., ketoconazole, miconazole,
clotrimazole) in conjunction with mild or moderately
potent topical corticosteroids may be used for more
severe cases (i.e., those with significant
erythema/inflammation). The corticosteroids are
typically applied for 2 to 3 weeks, while the antifungal
agent is used until active skin disease resolution is seen.

» Seborrhoeic dermatitis is a chronic, frequently


recurrent condition, so these medicines are likely to
be used intermittently over an extended time period.

Primary options

» ketoconazole topical: (2%) apply to the affected


area(s) once daily
TREATMENT

OR
» miconazole topical: (2%) apply to the affected
area(s) twice daily

OR

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» clotrimazole topical: (1%) apply to the affected
area(s) twice daily

adjunct topical corticosteroids


» Topical corticosteroids should be used only for more
severe flare-ups with marked inflammation and
erythema. Typically, their use should be limited to
periods of 2 to 3 weeks.

» When the disease flare-up is under control, the topical


corticosteroids should be discontinued and the
ketoconazole cream continued as needed (i.e., until
skin disease resolution is seen).

» Seborrhoeic dermatitis is a chronic, frequently


recurrent condition, so these medicines are likely to
be used intermittently over an extended time period.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

adjunct topical calcineurin inhibitors


» Topical calcineurin inhibitors can be used as an
alternative to topical corticosteroids. They would be
used until active skin disease resolution is seen.

» Seborrhoeic dermatitis is a chronic, frequently


recurrent condition, so these medicines are likely to
be used intermittently over an extended time period.

Primary options

» pimecrolimus topical: (1%) apply sparingly to the


affected area(s) twice daily

OR
» tacrolimus topical: (0.03 or 0.1%) apply sparingly
to the affected area(s) twice daily

with concomitant seborrhoeic plus oral azole antifungal under specialist direction
folliculitis or HIV infection » In cases with concomitant seborrhoeic folliculitis or
in HIV infection, treatment with an oral azole antifungal
(e.g., fluconazole) is indicated. This treatment would
be carried out under the guidance of a dermatologist
TREATMENT

or infectious disease specialist.

irritant contact dermatitis 1st irritant avoidance + supportive measures + topical


corticosteroids

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» The irritants should be identified and avoided or
reduced. Management is directed at education and
behaviour modification.

» Low- to medium-potency topical corticosteroid


ointments are prescribed to reduce symptoms.
Hydrocortisone is a low-potency topical corticosteroid
useful for mild disease. Triamcinolone is a
medium-potency corticosteroid useful for moderate
disease. Limit use to 2 to 3 weeks.

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

with significant pruritus adjunct oral antihistamines


» Oral antihistamines are useful for patients with
significant pruritus. Hydroxyzine is commonly used,
but may cause sedation.

Primary options
TREATMENT

» hydroxyzine: 25 mg orally every 6-8 hours when


required, maximum 100 mg/day

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of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2015. All rights reserved.
Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
allergic contact dermatitis 1st allergen avoidance + supportive measures + topical
corticosteroids
» Allergen(s) identified in history or confirmed by patch
testing should be avoided.

» Low- to medium-potency topical corticosteroid


ointments are a reasonable option to get the situation
under control. Hydrocortisone is a low-potency topical
corticosteroid useful for mild disease. Triamcinolone
is a medium-potency corticosteroid useful for
moderate disease. Limit use to 2 to 3 weeks.

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

with significant pruritus adjunct oral antihistamines


» Oral antihistamines are useful for patients with
significant pruritus. Hydroxyzine is commonly used,
but may cause sedation.
TREATMENT

Primary options

» hydroxyzine: 25 mg orally every 6-8 hours when


required, maximum 100 mg/day

severe with exudate/weeping adjunct wet soaks

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» Aluminium acetate soaks are a helpful treatment
adjunct in cases of severe acute contact dermatitis
with exudate/weeping. They can be used until active
skin disease resolution is seen.

Primary options

» aluminium acetate topical: apply towel soaked in


solution to affected area(s) for 20-30 minutes twice
daily

psoriasis 1st topical corticosteroid or topical calcineurin


inhibitor or topical vitamin D analogue + supportive
measures
» Hydrocortisone is a low-potency corticosteroid that
is used for mild disease. Triamcinolone is a
medium-potency agent used for moderate disease.
Use should be limited to 2 to 3 weeks.

» Topical calcineurin inhibitors or the vitamin D


analogue calcipotriene can be used as an alternative
therapy to topical corticosteroids, and to avoid the
potential of skin atrophy from excessive medicine
application. They are used until active skin disease
resolution is seen.

» Strong crude tar preparations should be avoided at


anogenital sites, as the skin at these sites tends to
absorb topical agents, leading to a heightened risk of
genital cancer (one of the first occupational diseases
described was scrotal carcinoma in chimney sweeps).

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.
TREATMENT

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

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of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2015. All rights reserved.
Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

Secondary options

» pimecrolimus topical: (1%) apply sparingly to the


affected area(s) twice daily

OR
» tacrolimus topical: (0.03 or 0.1%) apply sparingly
to the affected area(s) twice daily

OR
» calcipotriol topical: (0.005%) apply sparingly to
the affected area(s) twice daily

severe systemic disease plus specialist systemic treatment


» If psoriasis is very severe, systemic treatment with
acitretin, methotrexate, ciclosporin (cyclosporine), or
biological agents may be required. This treatment
should be carried out under the guidance of a
dermatologist.

Reiter's disease 1st topical corticosteroid or topical calcineurin


inhibitor + supportive measures
» The treatment of the skin disease is similar to that
for psoriasis.

» Hydrocortisone is a low-potency corticosteroid that


is used for mild disease. Triamcinolone is a
medium-potency agent used for moderate disease.
Limit use to 2 to 3 weeks.

» Topical calcineurin inhibitors can be used as an


alternative therapy to topical corticosteroids, and to
avoid the potential of skin atrophy from excessive
medicine application. They are used until active skin
disease resolution is seen.
TREATMENT

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» Patients should also avoid genital contact with
common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

Secondary options

» pimecrolimus topical: (1%) apply sparingly to the


affected area(s) twice daily

OR
» tacrolimus topical: (0.03 or 0.1%) apply sparingly
to the affected area(s) twice daily

with HIV infection plus oral retinoids under specialist direction


» Oral retinoids can be particularly useful, especially in
HIV infection. This treatment would be carried out
under the guidance of a dermatologist or infectious
disease specialist.

lichen sclerosus 1st topical corticosteroid ± antibiotic/antifungal


» The ultra-potent topical corticosteroid clobetasol is
effective for this condition. This agent is applied until
resolution of active skin disease is seen. Its use induces
re-modelling of the affected mucosa, relieves phimosis,
improves the histological signs, and can avoid the need
TREATMENT

for circumcision for disease treatment. The risk of


squamous carcinoma is also lowered by the treatment
course.

» The use of topical calcineurin inhibitors such as


tacrolimus ointment and pimecrolimus cream should
be avoided in this condition.[41] [42]

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» Antibiotics and antifungals are added as indicated by
specific findings of diagnostic testing.

Primary options

» clobetasol topical: (0.05%) apply sparingly to the


affected area(s) twice daily

2nd surgery-circumcision
» Surgical interventions range from circumcision,
frenuloplasty, and meatotomy to sophisticated plastic
repair, depending on the clinical presentation and the
site of greatest disease impact on the organ.

» Complete circumcision is the preferred treatment


because all affected tissue is removed and any
secondary involvement of the glans usually regresses
or resolves after the procedure.

gonorrhoea 1st antibiotics


» Patients should be treated with recommended
antibiotics for gonorrhoea. The CDC currently
recommends that ceftriaxone be used as a first-line
agent along with either azithromycin or doxycycline.
Azithromycin is preferred as it is given as a convenient
oral single dose and has decreased incidence of
gonorrhoea resistance compared with doxycycline.[40]

» If ceftriaxone is not readily available, cefixime plus


azithromycin or doxycycline is recommended. If the
patient has a severe cephalosporin allergy, a single high
dose of azithromycin is recommended. However, if an
alternative regimen is used, the CDC recommends a
test of cure 1 week after treatment.[40]

» Patients who have persistent symptoms after


treatment should be retested by culture, and if these
cultures are positive for gonococcus, isolates should
be submitted for resistance testing. Patients who
experience treatment failure after treatment with
alternative regimens should be treated with ceftriaxone
and high-dose azithromycin and should receive
infectious disease consultation. A test of cure should
be repeated 1 week after re-treatment. Treatment
failures should be reported to the CDC through the
local or state health department within 24 hours of
TREATMENT

diagnosis.[40]

» Clinicians should ensure that the patient's sex


partners from the preceding 60 days are evaluated
promptly with culture and treated as indicated. If a
heterosexual partner of a patient cannot be linked to

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
evaluation and treatment in a timely fashion, then
expedited partner therapy should be considered.[40]

Primary options

» ceftriaxone: 250 mg intramuscularly as a single


dose
--AND--
» azithromycin: 1 g orally as a single dose
-or-
» doxycycline: 100 mg orally twice daily for 7 days

Secondary options

» cefixime: 400 mg orally as a single dose


--AND--
» azithromycin: 1 g orally as a single dose
-or-
» doxycycline: 100 mg orally twice daily for 7 days

OR
» azithromycin: 2 g orally as a single dose

Tertiary options

» ceftriaxone: 250 mg intramuscularly as a single


dose
Infectious disease consultation required.
-and-
» azithromycin: 2 g orally as a single dose

plus supportive measures


» Patients should be advised to pay attention to
personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.
TREATMENT

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
candidosis 1st identify underlying disease + topical antifungal +
supportive measures
» Underlying disease should be identified and treated
and predisposing factors addressed.

» The antifungal agent is applied until resolution of


active skin disease is seen.

» Patients should be advised to pay attention to


personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Advise the patient to keep the area as cool and dry


as possible and advise wearing undergarments that
allow air to circulate (e.g., boxer-type underpants, white
cotton underwear).

» Partners may need treatment as well.

Primary options

» ketoconazole topical: (2%) apply to the affected


area(s) once daily

severe erythema/inflammation plus topical corticosteroids


» Topical azole antifungal agents are often very usefully
combined with hydrocortisone in cases with severe
erythema/inflammation.

» Use of topical corticosteroids should not be


continued for >2 to 3 weeks.

Primary options
TREATMENT

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

resistant to topical therapies or plus oral antifungal


severe/widespread involvement

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» Under certain severe circumstances an oral azole
antifungal (e.g., fluconazole) may be indicated if the
patient has not responded to topical therapies or if
there is severe/widespread involvement, as may be
seen in immunocompromised patients.

Primary options

» fluconazole: 50-100 mg orally once daily for 14


days

non-specific balanoposthitis 1st lower-potency topical corticosteroids


» Treatment can be very difficult as non-specific
balanoposthitis often does not respond to general skin
care measures, topical corticosteroids, and topical and
systemic antibiotics.

» Hydrocortisone is a low-potency corticosteroid that


is used for mild disease. Triamcinolone is a
medium-potency agent used for moderate disease.
Use should be limited to 2 to 3 weeks.

Primary options

» hydrocortisone topical: (2.5%) apply sparingly to


the affected area(s) twice daily

OR
» triamcinolone topical: (0.1%) apply sparingly to
the affected area(s) twice daily

plus supportive measures


» Patients should be advised to pay attention to
personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
area. Uncircumcised patients should fully dry the head
of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

» Use of soap substitutes (e.g., aqueous cream,


emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.
TREATMENT

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
adjunct targeted antibiotics or antifungals to treat
identified pathogens
» Antibiotics or antifungals are added as indicated by
specific findings of diagnostic testing.

2nd high-potency topical corticosteroids


» These agents are used when the condition does not
respond to treatment with lower-potency topical
corticosteroids, antibiotics/ antifungals, and supportive
measures.

» Intermittent application of the high-potency topical


corticosteroid clobetasol may provide benefit. This
agent is continued until resolution of active skin disease
is seen.

Primary options

» clobetasol topical: (0.05%) apply sparingly to the


affected area(s) twice daily

3rd surgery-circumcision
» Patients may have a difficult course with limited or
no response to consecutive treatment trials of topical
agents and other additional therapies (e.g., antibiotic
therapy).

» Circumcision is curative in most instances.

Zoon balanitis 1st high-potency topical corticosteroids


» Intermittent application of the high-potency topical
corticosteroid clobetasol may provide benefit. This
agent is continued until resolution of active skin disease
is seen.

Primary options

» clobetasol topical: (0.05%) apply sparingly to the


affected area(s) twice daily

plus supportive measures


» Patients should be advised to pay attention to
personal hygiene, but should avoid irritants such as
antibacterial soaps and over-washing of the genital
TREATMENT

area. Uncircumcised patients should fully dry the head


of the penis after washing.

» Patients should also avoid genital contact with


common allergens (e.g., perfumes, fragrant soaps,
detergents, and fabric softeners).

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Balanoposthitis Treatment

Acute
Patient group Tx line Treatment
» Use of soap substitutes (e.g., aqueous cream,
emulsifying ointment) once or twice daily and
emollients (e.g., petroleum jelly, aqueous creams,
lotions) when needed is indicated.

» Use of a lubricant during sexual intercourse can


improve symptoms of dyspareunia.

» Affected patients should wear white cotton


underwear.

adjunct targeted antibiotics or antifungals to treat


identified pathogens
» Antibiotics or antifungals are added as indicated by
specific findings of diagnostic testing.

2nd surgery-circumcision
» Patients may have a difficult course with limited or
no response to consecutive treatment trials of topical
agents and other additional therapies (e.g., antibiotic
therapy).

» Circumcision is curative in most instances.


TREATMENT

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Balanoposthitis Follow up

Recommendations
Monitoring

FOLLOW UP
Most patients will not need further monitoring once a diagnosis is made and their condition comes under control.

Patients with cancer or pre-cancer should be followed up regularly - at least once every 3 months or more frequently,
per local cancer guidelines.

Patient instructions
Patients should receive adequate and appropriate advice about the condition diagnosed, as well as a treatment plan
in case of recurrence or disease worsening. Patients with lichen sclerosus should be warned of the slightly increased
risk of squamous cell carcinoma and advised to present promptly if they note any change in the appearance of their
penile skin.

Complications

Complications Timeframe Likelihood


meatal stenosis long term medium

Can occur in children and adults following circumcision. Lichen sclerosis is not uncommonly determined to be the
aetiology in this circumstance.

Meatotomy is the definitive treatment.

Serial meatal dilation may lead to further stricturing and worsen the situation.

malignant transformation variable low

Concern regarding malignant transformation is particularly significant with non-healing eroded or ulcerated nodules.
Warty lesions not responding to usual therapy for genital warts can also potentially suggest malignancy.

In these instances, biopsy with histopathological interpretation is mandatory.

Prognosis

Most patients will improve following an accurate diagnosis and appropriate treatment. Monitoring and follow-up will
depend on the diagnosis, response to treatment, and risk of malignant transformation.

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Balanoposthitis Guidelines

Diagnostic guidelines

Europe

2013 European guideline for the management of balanoposthitis


Published by: International Union Against Sexually Transmitted Infections Last published: 2014

Summary: Includes recommendations on diagnostic tests for balanoposthitis.

2008 UK national guideline on the management of balanoposthitis


Published by: British Association for Sexual Health and HIV Last published: 2008

Summary: Recommendations on diagnostic testing for balanoposthitis. The guidelines concentrate on a selected
group of conditions, which may be managed by GU physicians, either alone or in conjunction with other specialists.
Aimed primarily at people aged ≥16 years presenting to GU medicine clinics.
GUIDELINES

Management of foreskin conditions


Published by: British Association of Paediatric Urologists Last published: 2007

Summary: Provides a concise overview of foreskin pathology and commonly associated conditions.

Treatment guidelines

Europe

2013 European guideline for the management of balanoposthitis


Published by: International Union Against Sexually Transmitted Infections Last published: 2014

Summary: Recommendations on treatment regimes for the effective management of balanoposthitis.

Guidelines for the management of lichen sclerosus


Published by: British Association of Dermatologists Last published: 2010

Summary: Provides evidence-based guidance on the treatment of lichen sclerosus.

2008 UK national guideline on the management of balanoposthitis


Published by: British Association for Sexual Health and HIV Last published: 2008

Summary: Offers recommendations on the diagnostic tests and treatment regimens needed for the effective
management of balanoposthitis. Concentrates on a selected group of conditions, which may be managed by GU
physicians, either alone or in conjunction with other specialists. It is not intended as a comprehensive review of the
treatment of all balanoposthitis. Aimed primarily at males aged ≥16 years presenting to GU medicine clinics.

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Balanoposthitis Guidelines

Europe

Management of foreskin conditions


Published by: British Association of Paediatric Urologists Last published: 2007

Summary: Provides a concise overview of foreskin pathology, commonly associated conditions and their treatment,
and issues important in the consideration of circumcision.

The law and ethics of male circumcision: guidance for doctors


Published by: British Medical Association Last published: 2006

Summary: Addresses important legal and ethical considerations encountered in medical and non-medical circumcision.
Consent issues are reviewed in detail. A framework for acting in the patient's best interests is presented.

North America

GUIDELINES
Update to CDC's sexually transmitted diseases treatment guidelines, 2010: oral
cephalosporins no longer a recommended treatment for gonococcal infections
Published by: Centers for Disease Control and Prevention Last published: 2012

Summary: The Centers for Disease Control and Prevention (CDC) has updated its gonorrhoea treatment guidelines
and no longer recommends the routine use of cefixime as data suggest that its effectiveness may be declining. The
CDC now recommends that ceftriaxone be used as a first-line agent along with either azithromycin or doxycycline.
Azithromycin is preferred as it is given as a convenient oral single dose and has decreased incidence of gonorrhoea
resistance compared with doxycycline. If ceftriaxone is not readily available, cefixime plus azithromycin or doxycycline
is recommended. If the patient has a severe cephalosporin allergy, a single high dose of azithromycin is recommended.
The CDC recommends a test of cure 1 week after treatment. Patients who have persistent symptoms after treatment
should be re-tested by culture, and if these cultures are positive for gonococcus, isolates should be submitted for
resistance testing. A test of cure should be repeated 1 week after re-treatment. Treatment failures should be reported
to the CDC through the local or state health department within 24 hours of diagnosis. Clinicians should ensure that
the patient's sex partners from the preceding 60 days are evaluated promptly with culture and treated as indicated. If
a heterosexual partner of a patient cannot be linked to evaluation and treatment in a timely fashion, then expedited
partner therapy should be considered, using oral combination antimicrobial therapy for gonorrhoea (cefixime 400 mg
and azithromycin 1 g as single doses) delivered to the partner by the patient, a disease investigation specialist, or
through a collaborating pharmacy.

Sexually transmitted diseases treatment guidelines, 2010


Published by: Centers for Disease Control and Prevention Last published: 2010

Summary: Comprehensive US guidelines covering all STDs, including a section on gonococcal infections.

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Balanoposthitis References

Key articles
REFERENCES

• Bunker CB. Dermatoses of male genitalia. In: Burns T, Breathnach S, Bleiker T, et al, eds. Rook’s textbook of
dermatology. 9th ed. New York, NY: Wiley-Blackwel; 2014. (In press)

• Edwards S, Bunker C, Ziller F, et al. 2013 European guideline for the management of balanoposthitis. Int J STD AIDS.
2014;25:615-626. Full text Abstract

• Bunker CB. Diseases and disorders of the male genitalia. In: Fitzpatrick's dermatology in general medicine. New
York, NY: McGraw-Hill; 2003: Chapter 3.

• Bunker CB. Topics in penile dermatology. Clin Exp Dermatol. 2001;26:469-479. Abstract

References
1. Bunker CB. Dermatoses of male genitalia. In: Burns T, Breathnach S, Bleiker T, et al, eds. Rook’s textbook of
dermatology. 9th ed. New York, NY: Wiley-Blackwel; 2014. (In press)

2. Edwards S, Bunker C, Ziller F, et al. 2013 European guideline for the management of balanoposthitis. Int J STD AIDS.
2014;25:615-626. Full text Abstract

3. English JC, Laws RA, Keough GC, et al. Dermatoses of the glans penis and prepuce. J Am Acad Dermatol. 1997;37:1-24.
Abstract

4. Wakatsuki A. Clinical experience of streptococcal balanoposthitis in 47 healthy adult males. Hinyokika Kiyo.
2005;51:737-740. Abstract

5. Cusano F, Capozzi M. Photocontact dermatitis from ketoprofen with cross-reactivity to ibuproxam. Contact Dermatitis.
1992;27:50-59. Abstract

6. Lyon CC, Kulkarni J, Zimerson E, et al. Skin disorders in amputees. J Am Acad Derm. 2000;42:501-507. Abstract

7. Gamulka BD. Index of suspicion. Case #1. Diagnosis: allergic contact dermatitis. Pediatr Rev. 2000;21:421-426.
Abstract

8. Ramam M, Khaitan BK, Singh MK, et al. Frictional sweat dermatitis. Contact Dermatitis. 1998;38:49. Abstract

9. Jacobson MA. Review of the toxicities of foscarnet. J Acquir Immune Defic Syndr. 1992;5:11-17. Abstract

10. Birley HDL, Walker MM, Luzzi GA, et al. Clinical features and management of recurrent balanitis; association with
atopy and genital washing. Genitourin Med. 1993;69:400-403. Full text Abstract

11. Reiter H. Ueber eine bisher unerkannte. Dtsch Med Woschensch. 1916;42:1535-1536.

12. Ridley CM. Lichen sclerosus et atrophicus. Br Med J (Clin Res Ed). 1987;295:1295-1296. Full text Abstract

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40 BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use
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Balanoposthitis References

13. Meffert JJ, Davis BM, Grimwood. Lichen sclerosus. J Am Acad Dermatol. 1995;32:393-416. Abstract

14. Powell JJ, Wojnarowska F. Lichen sclerosus. Lancet. 1999;22:1777-1783. Abstract

REFERENCES
15. Bunker CB. Diseases and disorders of the male genitalia. In: Fitzpatrick's dermatology in general medicine. New
York, NY: McGraw-Hill; 2003: Chapter 3.

16. Riddell L, Edwards A, Sherrard J. Clinical features of lichen sclerosus in men attending a department of genitourinary
medicine. Sex Transm Infect. 2000;76:311-313. Full text Abstract

17. Pelisse M. Lichen sclerosus. Ann Dermatol Venereol. 1987;114:411-419. Abstract

18. Feldmann R, Harms M. Lichen sclerosus et atrophicus. Hautarzt. 1991;42:147-153. Abstract

19. Datta C, Dutta SK, Chaudhuri A. Histopathological and immunological studies in a cohort of balanitis xerotica
obliterans. J Indian Med Assoc. 1993;91:146-148. Abstract

20. Bunker CB. Topics in penile dermatology. Clin Exp Dermatol. 2001;26:469-479. Abstract

21. Edmonds EV, Hunt S, Hawkins D, et al. Clinical parameters in male genital lichen sclerosus: a case series of 329
patients. J Eur Acad Dermatol Venereol. 2012;26:730-737. Abstract

22. Edmonds EV, Oyama N, Chan I, et al. Extracellular matrix protein 1 autoantibodies in male genital lichen sclerosus.
Br J Dermatol. 2011;165:218-219. Abstract

23. Edmonds EV, Bunker CB. Nuclear magnetic resonance spectroscopy of urine in male genital lichen sclerosus. Br J
Dermatol. 2010;163:1355-1356. Abstract

24. Bunker CB, Patel N, Shim TN. Urinary voiding symptomatology (micro-incontinence) in male genital lichen sclerosus.
Acta Derm Venereol. 2013;93:246-248. Abstract

25. Edmonds E, Barton G, Buisson S, et al. Gene expression profiling in male genital lichen sclerosus. Int J Exp Pathol.
2011;92:320-325. Abstract

26. Zoon JJ. Balanoposthite chronique cironscrite benigne a plasmocytes. Dermatologica. 1952;105:1-7.

27. Zoon JJ. Verenigingsverslagen. Ned Tijdschr Geneeskd. 1950;94:1528-1530.

28. Altmeyer P, Kastner U, Luther H. Balanitis/balanoposthitis chronica circumscripta benigna plasmacellularis - entity
or fiction? Hautarzt. 1998;49:552-555. Abstract

29. Bunker CB. Review of dermatology journals. Sex Transm Infect. 1999;75:281-282.

30. Yoganathan S, Bohl TG, Mason G. Plasma cell balanitis and vulvitis (of Zoon). J Reprod Med. 1994;39:939-944.
Abstract

31. Kiene P, Folster-Holst R. No evidence of human papillomavirus infection in balanitis circumscripta plasmacellularis
Zoon. Acta Derm Venereol. 1995;75:496-497. Abstract

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Balanoposthitis References

32. Catterall RD. In: Winner HL, Hurley R, eds. Symposium on candida infections. Edinburgh, UK: Livingstone; 1966:113.

33. Odds FC. Genital candidiasis. Clin Exp Dermatol. 1982;7:345-354. Abstract
REFERENCES

34. Eisendle K, Grabner T, Kutzner H, et al. Possible role of Borrelia burgdorferi sensu lato infection in lichen sclerosus.
Arch Dermatol. 2008;144:591-598. Abstract

35. Mallon E, Hawkins D, Dinneen M, et al. Circumcision and genital dermatoses. Arch Dermatol. 2000;136:350-354.
Full text Abstract

36. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays. 2007;29:1147-1158. Abstract

37. Rao A, Bunker CB. Male genital skin biopsy. Int J STD AIDS. 2011;22:418-419. Abstract

38. Bauer A, Geier J, Elsner P. Allergic contact dermatitis in patients with anogenital complaints. J Repro Med.
2000;45:649-654. Abstract

39. Bunker CB. Re: Sanjay Kulkarni, Guido Barbagli, Deepak Kirpekar, et al. Lichen sclerosus of the male genitalia and
urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol
2009;55:945-56. Eur Urol. 2010;58:e55-e56. Abstract

40. Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines,
2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal
Wkly Rep. 2012: 61;590-594. Full text Abstract

41. Bunker CB, Neill S, Staughton RC. Topical tacrolimus, genital lichen sclerosus, and risk of squamous cell carcinoma.
Arch Dermatol. 2004;140:1169. Abstract

42. Bunker CB. Male genital lichen sclerosus and tacrolimus. Br J Dermatol. 2007;157:1079-1080. Abstract

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Balanoposthitis Disclaimer

Disclaimer
This content is meant for medical professionals situated outside of the United States and Canada. The BMJ Publishing
Group Ltd ("BMJ Group") tries to ensure that the information provided is accurate and up-to-date, but we do not warrant
that it is nor do our licensors who supply certain content linked to or otherwise accessible from our content. The BMJ
Group does not advocate or endorse the use of any drug or therapy contained within nor does it diagnose patients.
Medical professionals should use their own professional judgement in using this information and caring for their patients
and the information herein should not be considered a substitute for that.

This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and any
contraindications or side effects. In addition such standards and practices in medicine change as new data become
available, and you should consult a variety of sources. We strongly recommend that users independently verify specified
diagnosis, treatments and follow up and ensure it is appropriate for your patient within your region. In addition, with
respect to prescription medication, you are advised to check the product information sheet accompanying each drug
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Contributors:

// Authors:

Ien Chan, MD, MRCP


Consultant Dermatologist
St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
DISCLOSURES: IC declares that he has no competing interests.

David Hawkins, FRCP


Consultant Genitourinary Physician
Chelsea and Westminster Hospital, London, UK
DISCLOSURES: DH declares that he has no competing interests.

Christopher Bunker, MA, MD, FRCP


Consultant Dermatologist and Honorary Professor of Dermatology
University College London and Chelsea & Westminster Hospitals, London, UK
DISCLOSURES: CB is an author of a number of references cited in this monograph. CB declares that he has no competing interests.

// Peer Reviewers:

Colm O'Mahony, MD, FRCP, BSc, DIPVen


Consultant in Sexual Health
Department of Sexual Health, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
DISCLOSURES: CO declares that he has no competing interests.

Sarah Edwards, MD
Consultant
Department of GU Medicine, West Suffolk Hospital, Suffolk, UK
DISCLOSURES: SE declares that she has no competing interests.

David Paige, MD
Consultant Dermatologist and Honorary Senior Lecturer
Dermatology Department, The Royal London Hospital, London, UK
DISCLOSURES: DP declares that he has no competing interests.

Jashin Wu, MD
Chief Dermatology Resident
University of California, Irvine, CA
DISCLOSURES: JW declares that he has no competing interests.

Christopher Huston, MD
Assistant Professor of Medicine
Contributors:
Division of Infectious Diseases, University of Vermont College of Medicine, Burlington, VT
DISCLOSURES: CH declares that he has no competing interests.

Nanette Silverberg, MD
Clinical Professor of Dermatology
Columbia University College of Physicians and Surgeons, New York City, NY
DISCLOSURES: NS declares that she has no competing interests.

Julian Trevino, MD
Associate Professor of Dermatology and Dermatology Residency Program Director
Boonshoft School of Medicine, Wright State University, Dayton, OH
DISCLOSURES: Speaker's Bureau, Stiefel; Consultant, Abbott.