New Guidelines Issued for Managing Patients With Balanoposthitis

New European guidelines outline the management of balanoposthitis in patients with penile skin conditions, as published in the Journal of the European Academy of Dermatology & Venereology.

The guideline is aimed primarily for managing penile conditions in patients aged 16 years and older and is an update to the 2014 edition. Evidence for the guideline is based on a literature search for English-language articles published up to May 2020.

The overall goals of managing patients with balanoposthitis are to minimize sexual dysfunction and urinary dysfunction, exclude penile cancer, treat premalignant disease, and diagnose and treat sexually transmitted diseases. Predisposing factors include poor hygiene, over-washing, nonretraction of the foreskin, and medical conditions such as diabetes. General recommendations include avoiding soaps when inflammation occurs and advising about risks of condom failure if creams are applied to the glans or foreskin.

Candidal balanoposthitis may include symptoms such as erythematous rash with soreness and/or itch. Treatments include clotrimazole cream 1%, oral fluconazole 150, and topical miconazole 2%. For anaerobic infection, management should include advice about genital hygiene, and circumcision may be needed in recurrent cases or when phimosis is present. The recommended treatment is metronidazole.

Clinical features of aerobic infection include variable inflammatory changes, such as erythema with or without edema. Treatment can be topical for mild symptoms, and severe cases may require systemic antibiotics while awaiting culture results. Recommended regimens include mupirocin ointment and clobetasone butyrate with nystatin and oxytetracycline cream.

Lichen sclerosus is characterized by itching, soreness, splitting, hemorrhagic blisters, dyspareunia, and problems with urination, such as postmicturition micro-incontinence or dribbling. Recommended regimens include soap-free washing and avoidance of contact with urine with barrier preparations such as petroleum jelly, weight loss, or removal of genital jewelry. Ultrapotent topical steroids also can be used.

Lichen planus features purplish, well-demarcated plaques on the glans and prepuce and on the shaft of the penis or erosive or annular lesions on the mucosal surfaces. Moderate to ultrapotent topical steroids such as clobetasol proprionate ointment are recommended, depending on severity, for mucosal and cutaneous disease.

Zoon balanitis (also known as plasma cell balanitis, is characterized by well-circumscribed, orange-red glazed areas on the glans and the inside of the foreskin, with multiple pinpoint redder spots. Recommended regimens include hygiene measures, management of underlying dermatoses, circumcision, topical steroid preparations with or without added antibacterial agents, antibacterial creams, and topical calcineurin inhibitors.

For management of psoriasis, moderate potency topical steroids once or twice daily are recommended until the condition is resolved. For eczema, the recommended treatment is topical hydrocortisone 1% applied once or twice daily until resolution of symptoms. Seborrheic dermatitis is characterized by mild itch or redness and can be treated with antifungal cream with a mild to moderate steroid.

For patients with fixed drug eruptions, management is symptomatic and topical steroids may be used until resolution. For premalignant conditions, patients with suspected penis cancer or precancer are best managed by specialists in dermatology and urology or andrology; a combined, sequential approach is frequently needed. The approach should include each patient’s specific clinical circumstances (ie, age, circumcision status, site/sites, comorbidities, and concomitant immunosuppression) and the pathogenesis and histology.

“The recommendations were made and graded on the basis of the best available evidence,” conclude the study authors. “However, high-quality evidence specific to the management of penile disease is not available for all the conditions described. Decisions to follow these recommendations must be based on professional clinical judgment, consideration of individual patient circumstances, and available resources.”