Treatment of Balanitis
The first-line treatment for balanitis depends on the underlying cause, with topical antifungal agents for candidal balanitis, topical antibiotics for bacterial infections, and topical corticosteroids for inflammatory causes, along with proper hygiene measures. 1
Diagnosis and Classification
Before initiating treatment, proper diagnosis is essential to determine the underlying cause of balanitis, which may include:
- Candidal infection (most common infectious cause)
- Bacterial infection (second most common infectious cause)
- Irritant dermatitis
- Poor hygiene
- Lichen sclerosus
- Other inflammatory conditions
Clinical presentation typically includes:
- Erythema and inflammation of the glans penis
- Pruritus
- Penile discharge
- Soreness or pain
- Burning sensation, especially during urination
Treatment Algorithm Based on Etiology
1. Candidal Balanitis
- First-line treatment: Topical azole creams (clotrimazole, miconazole) applied 2-3 times daily for 7-14 days 1
- Alternative: Single 150 mg oral dose of fluconazole, which has comparable efficacy to topical clotrimazole applied twice daily for 7 days 2
- Patients who previously received topical therapy often prefer oral treatment 2
2. Bacterial Balanitis
- First-line treatment: Topical antibiotics such as mupirocin ointment applied to the affected area three times daily 3, 4
- For severe cases or those not responding to topical therapy, oral antibiotics based on culture and sensitivity may be necessary 4
- Re-evaluation is necessary if no clinical response is seen within 3-5 days 3
3. Inflammatory/Non-infectious Balanitis
- First-line treatment: Topical corticosteroids for inflammatory causes 1
- For lichen sclerosus (balanitis xerotica obliterans): Potent topical corticosteroids (clobetasol propionate 0.05%) applied once or twice daily for 1-3 months 1
4. Zoon's Balanitis (Balanitis Circumscripta Plasmacelluaris)
- Topical mupirocin 2% ointment has shown success in treatment 5
- Alternative treatments include topical calcineurin inhibitors, phototherapy, and laser therapy 5
General Management Principles
Hygiene Measures (for all types)
- Gentle cleansing with warm water only
- Proper drying of the area after bathing
- Avoidance of tight-fitting underwear
- For uncircumcised men, proper retraction and cleaning of the prepuce
- Avoidance of irritants such as perfumed soaps 1
Follow-up and Monitoring
- Follow-up within 1-2 weeks to assess response 1
- If no improvement is seen after 72 hours of appropriate therapy, reevaluation is necessary 1
- Consider culture and sensitivity testing if initial treatment fails
- For recurrent cases, evaluation for underlying conditions may be needed
- Any fixed, chronic, or suspicious lesion should be biopsied to rule out malignancy 1
Special Considerations
- Recurrent balanoposthitis represents a strong indication for circumcision, especially in uncircumcised men 4, 6
- Prolonged steroid use can cause skin atrophy and other side effects, and should be used judiciously 1
- Aggressive cleaning can worsen irritation and inflammation 1
- Treatment of sex partners may be considered for partners who have symptomatic balanitis or penile dermatitis, but routine treatment of sex partners is usually unnecessary 7
Complications and Prognosis
- Most cases of infectious balanitis respond well to appropriate treatment
- Recurrence rates of approximately 12.7% have been reported in follow-up periods of 3-12 months 6
- Lichen sclerosus requires long-term follow-up due to 2-9% risk of developing penile carcinoma 1
By following this treatment algorithm based on the underlying cause of balanitis, most patients will experience resolution of symptoms and improvement in their condition.