Approach

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

General measures

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should:[1]

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

  • Avoid 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. Treat any underlying infections and conditions promptly with appropriate measures.

Atopic eczema

Treatment of atopic eczema includes application of emollients and topical corticosteroids.[1]​ 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.[1]

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

Identify and recommend avoidance of irritants, especially soaps and fragrances.[1]​ Prescribe topical corticosteroids. Oral antihistamines are useful for patients with significant pruritus.

Allergic contact dermatitis

Advise avoiding identified allergens and recommend the application of topical corticosteroids. 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 includes topical corticosteroids combined with emollients. Other treatments include topical vitamin D analogues (e.g., calcipotriene) or topical calcineurin inhibitors.[1]

In very severe disease, 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.

Reactive arthritis (Reiter's disease)

Treatment is similar to that used for psoriasis with topical corticosteroids or topical calcineurin inhibitor and supportive measures being employed initially.[1]​ In cases with concurrent HIV infection oral retinoids can be particularly useful.

Lichen sclerosus

Treatment is with a high-potency topical corticosteroid.[1]​ 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.[12][13]​​​[14]

Gonorrhoea

Treat patients with recommended antibiotics for gonorrhoea.[53][54][55] For more information on treatment see Gonorrhoea infection.

Candidiasis

Treat any underlying disease (e.g., diabetes, HIV).[1]​

Consider that it may be a secondary opportunistic complication of an underlying dermatosis, especially lichen sclerosus. In cases with severe erythema/inflammation, topical azole antifungal agents are often very usefully combined with hydrocortisone.[1]​ 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.

Advise the patient 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, or topical and systemic antibiotics. Consider subtle underlying lichen sclerosus. Surgical intervention (e.g., circumcision) may be necessary in the event of lack of response to medical treatment and is curative in most instances.[33]

Zoon balanitis

Consider that it may represent underlying lichen sclerosus. Prescribe an intermittent application of moderate to high-potency topical corticosteroid (e.g., betamethasone, clobetasol) with or without antibiotics and antifungal agents.[1]​ Surgical intervention (e.g., circumcision) may be necessary in the event of lack of response to medical treatment and is usually curative.

Carcinoma in situ/penile intraepithelial neoplasia (PeIN)

This should be managed in specialist centres by a multi-disciplinary team.[1]​ Only about 15% of patients with PeIN will respond to topical treatment alone.[25]​ Offer circumcision if the patient is not already circumcised. Topical agents such as fluorouracil, salicylic acid, podophyllum resin, and imiquimod can be used singly or in combination, and cyclically. The use of these topical agents in carcinoma in situ/PeIN is off-label and will reflect the individual clinical circumstances and the experience and competence of the treating physician; it is an expert area. 

Cryotherapy, hyfrecation, lasers, and photodynamic therapy may be employed. Curettage and cautery, excision, Mohs micrographic surgery, and glans resurfacing are surgical options.

In the presence of human papillomavirus (HPV)-driven undifferentiated PeIN, there is a compelling rationale for post-exposure HPV vaccination, although evidence is limited.​[35][36]​[37]​[38]​​

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