| 2013 European guideline for the management of balanoposthitis
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Clinical features
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Diagnosis
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Management
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Recommended regimen
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Alternative regimens
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Follow-up
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Other recommendations
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| Lichen sclerosus
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White patches on the glans, often with involvement of the prepuce. There may be haemorrhagic vesicles, purpura and rarely blisters and ulceration. Architectural changes include blunting of the coronal sulcus, phimosis or wasting of the prepuce, and meatal thickening and narrowing.
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Diagnosis is with Biopsy
- Epidermis: Thickened epidermis which then becomes atrophic with follicular hyperkeratosis.
- Dermis: Dermal hyalinisation with loss of elastin fibers and underlying perivascular lymphocytic infiltrate
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- Ultrapotent topical steroids(e.g. clobetasol proprionate) applied once daily until remission, then gradually reduced. Intermittent use (e.g. once weekly) may be required to maintain remission. A double-blind study in children showed response to topical mometasone furoate, particularly in early cases without scarring.
- In view of the immunosuppressive effects of potent steroids, patients with a history of genital warts should be warned about the risk of a relapse; consider prophylactic acyclovir in patients with a history of genital HSV infection.
- Secondary infection should be treated.
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- Although topical calcineurin inhibitors have been claimed to be efficacious (pimecrolimus applied twice daily, there is concern about the risk of malignancy.
- Surgery may be indicated to address symptoms due to persistent phimosis or meatal stenosis.This may include circumcision, meatotomy or urethroplasty.
- Circumcision is indicated for failed topical medical treatment.
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- Patients with a persistent requirement for topical treatment should be circumcised.
- Patients with atypical or persistent lesions should receive more specialist input.
- Patients should be advised to contact the general practitioner or clinic if the appearances change.
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| Lichen planus
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Purplish lesions, or supporting evidence of lichen planus lesions elsewhere on the body. This particularly includes the mouth in cases of erosive (penogingival) disease
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Biospsy
Irregular saw-toothed acanthosis, increased granular layer and basal cell liquefaction.
Dermis: Band-like dermal infiltrate (mainly lymphocytic).
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Moderate to ultrapotent topical steroids depending on severity (for both mucosal and cutaneous disease)
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- Topical and oral ciclosporin have been used for erosive disease.
- Topical calcineurin inhibitors have also been tried in lichen planus of the vulval and oral mucosa (pimecrolimus applied twice daily, but no specific reports in penile disease (noting the caution as for lichen sclerosus).
- Circumcision: May be the treatment of choice for some cases of erosive lichen planus
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- Patients with a persistent requirement for topical treatment should be circumcised.
- Atypical or persistent disease should receive more specialist input.
- Patients should be advised to contact the general practitioner or clinic if the appearances change
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| Zoon’s (plasma cell) balanitis
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well-circumscribed orange-red glazed areas on the glans and the inside of the foreskin, with multiple pinpoint redder spots – ‘cayenne pepper spots.’ These are in a symmetrical distribution
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- Epidermis: Epidermis thickening which is followed by epidermal atrophy, at times with erosions.
- Dermis: Plasma cell infiltrate with haemosiderin and extravasated red blood cells.
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- Circumcision – this has been reported to lead to the resolution of lesions.
- Topical steroid preparations – with or without added antibacterial agents e.g. Trimovate cream, applied once or twice daily.
- Hygiene measures.
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- CO2 laser – this has been used to treat individual lesions
- Although topical tacrolimus has been reported in the treatment of Zoon’s balanitis. there is controversy about the risk of malignancy with the use of topical calcineurin inhibitors
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- Dependent on clinical course and treatment used, especially if topical steroids are being used longterm.
- Penile biopsy should be performed if features are atypical or do not resolve with treatment.
- It should be remembered that there are cases where even biopsies failed to identify pre-malignant disease.
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| Psoriasis
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circumcised male psoriasis on the glans is similar to the appearance of the condition elsewhere, with red scaly plaques.
uncircumcised scaling is lost and the patches appear red and glazed.
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Biopsy:
Parakeratosis and acanthosis with elongation of rete ridges. Collections of neutrophils in the epidermis may be present.
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- Moderate potency topical steroids( antibiotic and antifungal).
- Emollients
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- Topical Vitamin D preparations (calcipotriol or calcitriol applied twice daily)
- Topical bethamethasone dipropionate/calcipotriol ointment may be well tolerated in treatment of anogenital psoriasis, but potent steroids may not be indicated
- Topical tacrolimus has been used in small studies42 but should not be used as first-line therapy
- Topical pimecrolimus can also be useful.
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| Circinate balanitis
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Typical appearance: greyish white areas on the glans which coalesce to form ‘geographical’ areas with a white margin. It may be associated with other features of Reiter’s syndrome but can occur without.
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.Biopsy:
Epidermis: Spongiform pustules in the upper epidermis.
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- Screening for STIs. Syphilis can also give rise to similar features.Consider testing for HLAB27.
- A positive test can confirm a diagnosis and provide important information about the risk of associated disease, such as urethritis, gastrointestinal disease and arthritis
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Sexual partners . If an STI is diagnosed, the partner(s) should be treated as per the appropriate protocol.
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. May be needed for persistent symptomatic lesions. . Associated STIs should be followed up as per appropriate guidelines.
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| Eczema
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Symptoms ranges from mild non-specific erythema to widespread oedema of the penis.
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Biopsy: eczematous with spongiosis and non-specific inflammation.
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- Hydrocortisone 1% applied once or twice daily until resolution of symptoms
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- In more florid cases more potent topical steroids may be required and may need to be combined with antifungals and/or antibiotics.
- Hydrocortisone 1% applied once or twice daily until resolution of symptoms
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- Not required, although recurrent problems are common and the patients need to be informed of this.
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- Avoidance of precipitants – especially soaps.5 . Emollients – applied as required and used as a soap substitute.
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| Seborrhoeic dermatitis
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Mild itch or redness (less likely to have scaling at this site)
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Antifungal cream with a mild to moderate steroid.
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- Oral azole itraconazole
- Oral tetracycline
- Oral terbinafine may be effective43
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| Fixed drug eruption
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Well demarcated and erythematous, but can be bullous with subsequent ulceration
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Biopsy:
- Hydropic degeneration of the basal layer
- Epidermal detachment and necrosis with pigmentary incontinence.
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- Condition will settle without treatment .
- Topical steroids – e.g. mild to moderate strength twice daily until resolution
- Rarely systemic steroids may be required if the lesions are severe.
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| Non-specific balanoposthitis
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Chronic symptomatic presentation with relapses and remissions or persistence. No unifying diagnosis and poor response to a range of topical and oral treatments.
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- Failure to respond to maximal topical steroid and antifungal treatments (including potent steroids). Non-specific histology on biopsy. Non-specific histology at circumcision. No evidence of underlying infective cause (e.g. Chlamydia or mycoplasma).
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Circumcision is curative.
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