| 2013 European guideline for the management of balanoposthitis
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Distinguishing clinical features shown on the penis
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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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| Lichen sclerosus
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- White patches on glans, which may often involve prepuce.
- Haemorrhagic vesicles, purpura with rarely blisters and ulceration may be present .
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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.
- 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 is indicated when lesion are associated with phimosis and meatal stenosis. Surgical procedures include circumcision, meatotomy ot urethroplasty.
- Circumcision is indicated for failed topical medical treatment.
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- Persistent requirement for topical treatment is an indication of circumcision.
- Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
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| Lichen planus
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- Purlish lesions on the
- Presence of lichen planus lesions elsewhere in body
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Biopsy
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
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- Topical and oral ciclosporin have been used for erosive disease.
- Circumcision: May be the treatment of choice for some cases of erosive lichen planus
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- Persistent requirement for topical treatment is an indication of circumcision.
- Patients should be advised to contact the health care provider if they notice any change in appearances of the lesion.
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| Zoon’s (plasma cell) balanitis
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- Well-circumscribed orange-red glazed areas on the glans and foreskin.
- Multiple symmetrical pinpoint redder spots – ‘cayenne pepper spots.’
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Biopsy
- 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
- Topical steroid preparations - Trimovate cream, applied once or twice daily.
- Hygiene measures.
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- CO2 laser
- Topical tacrolimus
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- In atypical cases or cases which do not resolve with with treatment penile biopsy should be performed.
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| Psoriasis
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Circumcised male
Red scaly plaques
Uncircumcised
- Patches appear red and glazed
- Scaling is lost
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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 studies 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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- Greyish white areas on the glans
- These areas may coalesce to form ‘geographical’ areas with a white margin
- Usually associated with Reiters syndrome
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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
- STD's: Sexual partners should be tested for STD's.
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Follow up may be needed in persistent symptomatic lesions.
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| Eczema
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Eczema may present has mild non-specific erythema to wide spread edema on penis .
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Biopsy
Eczematous with spongiosis and non-specific inflammation.
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- Patients should be advice to avoid precipitants(Soap) and apply emollients.
- Hydrocortisone 1% applied once or twice daily until resolution of symptoms
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- Potent topical steroids combine with antifungal and antibiotics may be needed in florid cases
- Hydrocortisone 1% can be applied until resolution of symptoms
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- Follow up is usually not required.
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| Seborrhoeic dermatitis
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Mild itch or redness
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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 lesions.
- Lesion may be bullous and may undergo 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.
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- Failure to respond to maximal topical steroid and antifungal treatments.
- Non-specific histology on biopsy.
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Circumcision is curative.
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